HomeMy WebLinkAboutApp-Permit-ComplianceNo. olnc- l9 -0(,q0-7 �, 1.772 -ao-bo 1A,3 FEC v r
3 COMMONWEALTH OF MASSACHUSETTS -6836
Board (fflealth, baymckx h MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
" ? AI plication fm• a Permit to Consn-uct( ) RepaUpgrade( ) Abandon( - ElComplete System ❑ Individual Components
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Owner's Name
ap/Parcel#
00-70
Address ?-a. N.
lwf4 . S'T,
Lot#
Telephone#
Installer's Name
Designer's Name
d 1 y
Address
Address
Telephone#
O
Telephone#
— t y
Type of BuildingY
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Lot Size B I sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. re t�'ir%ed gpd Calculated design flow Design flow provided,d
�5 y� gp
Plan: Date
--__� T� �i Numb& of sheets _ Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree n place t L.. in operation until a Certificate of Co plian ' has been issued by the Board of Health.
Signed---�--- Date
Inspections
COMMONWEALT14 OF MASSAC14USETTS
1\ � 60,
Board oftlealtla, 'blTlllXB ? MA. Syi A ^fl
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System ��,,,�;dt
The undp siglied hereby certify that the Selvage Disposal System; Constructed ( ),Repaired»(.,.,), Upgraded ( ),Abandoned ( )
by:�,..pC"_. '
at ZF �• "6,leV 719 s° ,n;,V1 4r-&" B 'U Y-tVs0
has been installedd in accordance with the provisions of 31_0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.._d1' -" dated `'�"' , > "" 6'N°Approvcd Design Flow .) (' (gpd)
Installer 1`y`"� °C` .§ I -- 610—V A -A) 11-51
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Desimer:l �. /°�iA"A .'..l11 Insnecto: 1 -51i577^1" Date:
.........The issuance of.this permit sball not be construed as a guarantee that the system will function as designed. - - -
No.
COMMONWEALTH OF Mi ASSACI-IIISI TTS de -z! 16 2)
Board of Health, ) a�-Moo"",—AL , MA.
DISPOSAL SYSTE M CONSTRUCTION PERMIT
Permission istherebygr ntedto; Construct( ) Repaiyi,Wp) Upgrade( ) Abandon( ) an individual sewage disposal system
at A/I ¢r i 7) a -rl as described in the application for
Disposal System Construction Permit No. 17 A1` , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/95 AM, Bulkln Ce. ChedeR N@N% Date �7 t' � F Board of Health
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