HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONNAAbUfAJ AA %% PSETTS
Board of A, ROUTE 28 MA.
SO. ,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Application for a Permit to Construct( ) Repair( ) Upgrade Abandon ( ) - O Complete System O Individual Components
Location 47 -e-ve-Gun/ s j.. S )/ ,n
Owner's Name Ta 7
Map/Parcel#
Address yam, -�.�r, p„/ x P—
Lot#
Telephone#
Installer's Name
C G!✓.�'
Designer's Name E , S•Un �, d y�,r�
Address
. -' �,✓,1
Address r� �, y- G ,� /✓'.
Telephone
G,F-��3YGS� d
Telephone# •3
Type of Building Lot Size sq. ft.
Dwelling -No. of Bedrooms �C 5n)x Garbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures 7�
Design Flow (min. required) % �'(d gpd Calculated design flow Design flow provided :// gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
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 agrees to of to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signem'G • Date / J�
hnspections
COQ' MONWFALTT-I OF MASSACTIUSLTTS FET
F� d
Board ofFlaalth, 4, ",;7.1 `0 , MA. Y
CERTIFICATE OF COMPLIANCE
Description of Work: O Individual Component(s) OComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (`), Abandoned ( )
at 4;'� , :'% r'.. --a �- ,V _5 .T G. a•;ril,. rain r.— ,��
has been installed in accordance with the pt ovisions of,410 CMR 15.00 (Title 5) and the, al rovect design plans/ is built plans ui-clat)ing to„
application No. 1(�>'�"� dated 23'%"' "-'%' . Approved Design Flow "' dy' (gpd) "`;;,Fp"�''
Installer /=
Designer: �' ''e4 /�� af,�.'z v✓r. t,:. e' ' hnspecwr: `',.%.. °..1a`, `. 3 ..).>: Z'`¢`V� Date: -,,co
The issuance of this permit shall not be construed as a guarantee thaelthe system will function as designed.
No. �'R ~^a't T".. ,...✓t.,._,... FEC
COMMONWEALTH OF MASSAGNUSTTT'S
Board of Health, A'� t t .P'' , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(, Abandon( ) an individual sewage disposal system
at d ° fix i `�` >,t I _-,/�'`e� r ?"' as described in the application for
Disposal System Construction Permit No. dated /6- r •'�' <
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. 5196 N.M. 6ulkln Co. Boston, MNDatC ` B02Cd Of 1-12a1Lh-✓'4^�°-=-f�