HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 7ro FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health,, 140 KOUTE 28 1 ARMOUTH HEALTH DEPPT.
A
APPLICATION FOP DISP TA9V9V ""RUCTION` PERMIT
Application for a Permit to Cons uct( epair( ) Upgrade( ) Abandon() - omplete System ❑ Individual Components
Location
13rU v IZ
Owner's Name -pt-, S (. , ( jr SFvc1C �c�
Map/Parcel#
513
Address
Lot#
Telephone#
Installer's Name L,
�I,, s ✓ tJ-e S
Designer's Name -C/- E-15
Address
3 5
Address
Telephone#
-� o
�Zt Z
Type of Building t cem h Lot Size sq. ft.
Dwelling - No. of Bedrooms �D f/ 3 i' �J� Garbage grinder (A)a
Other - Type of Building
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) / lU 3'1 z gpd Calculated design flow 4 G O Design flow provided to plc ^ lS gpd
Plan: Date Number of sheets l Revision Date /�
Title ��i o �/S i S`t/' IL, b � S �S �. Luh f �� y, %3 r ao� 2� t,> r SF i �S -/hD 4 . /k e
Description of Soil (s) -P(,g 1-% `
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
a The undersile'da eesto install the above described.Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
- wfurther agreno to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
to Signed Date
Inspections
No. � FEE J f
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) �P Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed t q, Repaired ( ), Upgraded ( ), Abandoned ( )
by: L. C.
at /' / 7 i v,,, . 0 ro r k- 6) 0 2
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. D S '-76 dated -3 Approved Design Flow (gpd)
Installer G' �' t �, S-1 S . J C
Designer: S W{ t f Sf z a S• Inspector: ,� ! Date: 1! -zL5;-
The issuance of this permit shall not be construed as a guarantee t the system will function as designed.
No. FEE
CO9[MONWLA T14 Of MASSACHUSETTS
Board of Health, (id, W �,Z MA.
DISPOSAL. S 11 STiCM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 5 1A T as described in the application for
Disposal System Construction Permit No. D-76 dated
6 l90
Provided: Construction shall be completed within thre,�y of the date of this p it. All local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date // �� Board of Health