HomeMy WebLinkAboutApp-Permit-Compliance` No.
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�,&OMMONWFALTII OF MASSACHUSETTS
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Board of Health, �,�/moLi MA.
° APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair((pgrade( ) Abandon( - .11dComplete System 0
FEE V ✓W
03
,R 0 9 2018
HEALTH DEPT.
Location
Owner's Name
Map/Parcel# % �-�-'
Address ��i/J' c•Gs1 AV
Lot#
Telephone#
Installer's Name
Designer's Name
Address -_ �r�av
Address
Telephone# -oy7.7 $r- ,7
Telephone#_s-
Type of Building Lot Size Qdt3 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) -3,.3CG gpd Calculated design flow
Plan: Date / %/"f Number of sheets %
Title ��,= S.fe /C'�a rP
Description of Soil (s) _
Soil Evaluator Form No
Name of Soil Evaluator
Design flow provided 3 -'d- gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS ��tsJ s�l� /l/rry ! 3 �o G' / 'L
y — 11-Z Z6MZi61 q 11121 L y Zoe
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees/tot to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ��x% �' ��' Date 3��
.,
Inspections
(a n
Description of Work:
The
by: _
at
Board of Health; _
GERTIFICATE-OF COMPLIANCE
❑ Individual Component(s) @-Complete System
hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned
t
has been installed in accordance with the.provisions of 310,CMR 15.00 -'(Ti le 5) and the approved design plans/as-built plans relating to
application No. _�0 c -dated L Approved Design Flow 3 6 (gpd)
Installer
Designer:Y Inspector: �0 �,/- `�/\l �►y Date: t
The issuance of this permit shall not be construed as, a guarantee that the system will function as designed. -;
No. Jb ti ffl) C S -2-6 8C7 CAh l_() D SL - c Svcs . FEE JY 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, f� �. ry .f (,� , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at
Repair( 4-)' Upgrade ( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkiin Co. Boston, M Date /Zard of Health