HomeMy WebLinkAboutApp-Permit-Compliancet No.
C®MM®NI SALT AR
OF MASSACHUSETTS
YMOUTH HEALTH DEPT.
Board of Health, 'APPLICATION
, MA.
D /�� �T it ROUTE a.
I7 P LICATIO FOR DISP®S -
"r
'l.l'MCTIO PERMI1
FEE O�
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - Xcomplete System ❑ Individual Components
Location �2/
e?Lv iii/P/hS
Owner's Name e-, � GL Iv Gava7
Map/Parcel#
Address f',p�
Lot# 3
OS3
Telephone#
Installer's Name
J-
Designer's Name �G G
Address
S'��� y e ti
Address G C Oma• /��S G s�-',r
Telephone#
Telephone# ,Kr V/l
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 33 0 Design flow provided Y&I- gpd
Plan: Date `V/Z p 1;. Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS _T�S%/a/i �"G a y�oc %/�/� 19- 03 ria 3 X—e-
iii r 4✓i7I/ _r7o.--
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ,-!,--,_ Date
Inspections
No. FEE
COMMONWEALTH Of MASSAC14 SETTS
Board of Health, �Ili�iLlUL / y1 MA.
CERTAILAR of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by:
at
has been installed in acc� n e with the provisions of 3 0 CMR 15.00 (Title 5) and the,appr ved design plans/as-built plans relating to
application No. dated �l%' -� . Approved Design Flow '3"T' gpd)
Installer
Designer: ���� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 19 r a4l a -
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 7'1'1 • , MA.
DISPOSAL SYSTEM CONSTRUCTION -PERMIT
Permission is hereby granted to; Construct( ) Repair(
at
SWUM
FEE
Upgrade (l� Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. G(0 �� dated �Q r
Provided: Construction shall be completed within ''/+--6e=�rs of the date ofthis All local condi ' s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date DSL! �v Board of Health V