HomeMy WebLinkAboutApp-Permit-ComplianceNo. 604kv FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V1`19-vt . - MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUWO P MIT
Application for a Permit to Construct( ) Repair (el./upgrade ( ) Abandon( ) - ❑ Complete Systemdividual Components
Location o in bN
Owner's Name Sco n
Map/Parcel# '79z/Address
aN S I�\ "'
Lot#
Telephone#,50??-M[5-155q
Installer's NameCDA i nom, Z a
Designer's Name 00wo
Address -0 50a
Address (1'JC� �� C ` Qa�p7'"
Telephone#?J-006-775-R20
Telephone# --
Type of Building .5�. ,fig l �/ Lot Size 1�2 Z2 r sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided Zgpd
Plan: Date �� zef Number of sheets / Revision Date /2, %fes
Title 'iii/G LS /�, j{P l�lc'o"-f o
Description of Soil(s) �1c- �i� JG � a-,
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 4r -s Pi
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees two 5" place the system 'on until a Certificate of Com fiance has been issued by the Board of Health.
Signed �- Date
Inspections
No. U � � V � I I� FEE e 00
4tz;COMMONWEALTH Of MASSACHUSETT
r
Board of Health,. ��* , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: dIndividual Com onent(s) ❑ Complete System
�u
P P P ys
The undersigned hereby certify that the Sewage Disposal System; Constructed. ( ); Repaired , Upgraded'' , Abandoned ( )
by: - m ! i�J�%d r`' e� !01
atcrFr
has been installed ' acco d ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
�.
application No dated`. Approved Design Flow (gpd)
Installer
Designer: i1 CA Pte_ L�-QG-i 0 r Inspector: t.�f' Date:
o:
The issuance of this permit shall not be construed as a guar a that :the system will function as designed.
No.C `` t j rY i. i 0-0 StC 1 C- S VCS FEE
C®MM®NTAITH OF MASSACHUS ETT Z a
Board of Health,`MA.
DISPOSAL SYSTEM CONSTRUCTION -PERMIT
Permission is hereby granted to; Construct( .) Repair(/,/) Upgrade(VI/Abandon ( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. Y----—' dated l /+Q
Provided: Construction shall be completed within 44-r-�Hothe date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date t 10 Board Of Health
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