HomeMy WebLinkAboutApp-Permit-ComplianceNo. l/ �/ - FEE J ,� Comm0t -
�) ASSACIIUSETTS / 73 7
C
/� 1 I u t i�
S'/// �8 �� Board ofPlealth, 1148 ROUTE 26 , MA.
Y
APPLICATION FOR DIS PO 'L M31 C6NSTRUCTION PERMIT
tz fonfor a Permit to Construct( Repair( Upgradc�Abandon O -�t eomplete System ❑Individual Components
Location yv TR CTQ',.Q
Owner's Name Q S�s
Map/Parcel# s - a a
Address a. \ o t fe QK
Lot# " 3
Telephone#
Installer's Name Cc Q w ,(\ SF
Designer's Name
Address L/SU-1 �G`+�o � c) cc) ['tr
Address \Z teles\' ceu'zs 2 iT-"s4dca
Telephone# SO 42$
Telephone#
Type of Building V2 a
Dwelling - No. of Bedrooms.
Other -Type of Building _
Other
Design Flow (min. required) 3 3
Plan: Date 3- I -L -
Title
Description of Soil (s) 0
Soil Evaluator Form No.
No. of persons
Lot Size r2 \ t O $ 7 sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow .3 0 Design flow provided
Number of sheets e2. Revision Date
ocv \A "— 3Cen tv911
Name of Soil Evaluator
c ' `•k) Date of Evaluation .3— t0- t b
gpd
DESCRIPTION Or REPAIRS ORALTERATIONS )VI,,u I c+1 ft w Q I c� tn. i li' r a3 S I-t,.n �w�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
f irther agrees to not place a system in operation untila Cer if' of Compliance has been issued by the Board of Health.
Date R
II5''0
Inspections
No. °'i°� FEE �' t
COMMONWEALTH OF MASSACHUSETTS
Board of health, v ""
CERTIFICATE'OF COMPLIANCE
Description of Work: CI Individual Component(s) ,-CI-Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraclecl,(' /, Abandoned ( )
by: ar'ncatC t
at 1
has been installed it
application No.'�
r`a
Installer
Designer: s. t
The issuance of fill,
with the provisions of 310 CMR / 15.00 (Title 5) and the approved design plans/as-built plans relating to
,*
dated A Approved Design Flow T (gpd)
Inspector:
Date:
permit shall not be construed as a guarantee that the system will function as designed.
r
COMMONWEALTH OF MASSACHUSETTS
Board of health, (--T �' /rd 1��� / `7 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
kil,
FEC
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(//) Abandon( ) an individual sewage disposal system
at g / as described in the application for
Disposal System Construction Permit No/,) �T Y , dated
6�tua y"
Provided: Construction shall be completed within th -ee-years of the date of this permit. All local conditions must be met.
Farm 1255 Ren 5/98 A.M. Sultrin Co. Boston, MA Date ' �.? _.l Board of Health � �� (����-�r"'� � �.-+�✓� ^^'�
>✓ar"v`�' rv'J ,f:%Ur✓�ysf„'C�' �'``� L G. -!.e ' f` �.cr'-.,,G;,L�. �..