HomeMy WebLinkAboutApp-Permit-ComplianceNo. a
Ltw v
FEE
Board of Health, %Gr �'� �' / �' MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
ZA
ante ]Zp 01 trgwa�
Owner's Name ovk )PCJA tr[-
Map/Parcel#
-4((1
9G 6,&-41�PqAddress
a ,,.�r►,�t �� /�/, r-,� �?'Fl va�73
Lot#
Telephone# Sp�, - r S- L>
Installer's Name �j�� t �.�
Designer's Name
Address 3,S -U
Al'. .0
a j*,uvA M4 Oa -C-7 3
Address
Telephone# _5-0r,
- 22s-
- P - m
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS /�iKinc L+n¢ TYcJv�l ''t'd'^ ?0 8✓8+{%a L- CfSSf�freL,
.10 SGA I,/U Fy c
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 L/ a3 OS
Inspections
No. O �v
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
l�
FEE `
��
Ihi �-��
Description of Work: 1��ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired�Upgraded ( ), Abandoned O
by: d/v-C
at
has been installed 'A accordance with the provisions o 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
w _ application�No. , dated �`.z 3-� Approved Design Flow �- (gpd)
Installer J?lke .d*e-
Designer: Inspector: �2e4 � Date: ox/.;Z31
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.0 -7t/G�(�Cs�'�'/'` �/' FEE
COMMONWEALTH Of MASSAC14USETIS
Board of Health, MA. N 0�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair% Upgrade ( ) Abandon ( ) an individual sewage disposal system
at F1) p %✓� VCs/'7r.�� as described in the application for
Disposal System Construction Permit No. dated -;- -c d
Provided: Construction shall be completed within e-yoars of the date of Zh�er$ All local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -5h e " Board of Health /
J