HomeMy WebLinkAboutApp-Permit-ComplianceNo. E0 -.3001 FEECOMMONWEALTH Of MASSAC14USETTS
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Board of Health, MA. ze
APPLICATION FOR DISPOSAL SYSTEM C®NSTRUCM fERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location 1-
Aery e�RC1
Owner's Nam a,�
Map/Parcel# -3-9
Address
Lot# -2-
Telephone# dt 0- SZ!;-, 72;Y,27
Installer's Nam
Designer's Name o
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Address
Q� , sT sy G
Address s e or
Telephone#_
7��_ aB2�!'
Telephone#
Type of Building �5rs�?4'%%" !i/ Lot Size / 7G�< 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 3V,5r- > gpd
Plan: Date� ;3/3 �� Number of sheets Revision Date
Title
Description of Soil(s) %✓t �s�irc' - il�l���o� �5"rr• Hc� a?� �- yo r•
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 7, J -.>X
C 141AfA >S 1.,14VW 7-4aA& / �. 8 x
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 m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed � e Date
Inspections E4 I -t
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No.
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C®MONWEALT14®F I� ASSAC14US ETTS FEE
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Board of Health, Ytr fp MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ndiv,dual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (41 -,/Upgraded ( ), Abandoned () ,Sri`
by:
has been installed ncorsl�� with the provisions 3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / dated �j /G Approved Design Flow ,F4 d: T(gpd)
Installer
Designer: "-G 1 NC -E -R..1 N 6- LAN)' &Z Inspector: 15 cc —-Date:
the
The issuance of this permit shall not be construed as a guarantee that e system will function as designed.
No. 60JA -t , -3001 CAP( --COD 5-evT-?C SVC S FEE Qb
COMMONWLALT14 OF MASSAC14USETTS Ck*2sb0
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at / 5 /11-
_ r as described in the application for
Disposal System Construction Permit No. dated
�o�
Provided: Construction shall be completed within thof the date of this perm All local con 'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA ' Date t? tard of Health l
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