HomeMy WebLinkAboutApp-Permit-CompletedNo. x—
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J W �(UdCOIMMONWEAETH OF MASSACHUSETTS
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YiIR01,11OUTH HEALTH DA,rEP'
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APPLICATION FOR DISPOTRISAYS-RiR � T [JCTION PERMIT
Application fora Permit to Consn-ttct( ) Repair( ) Upgrade( ) Abandon( ) - A Complete System ❑ Individual Components
Location GS�o�j/�GO�{i
,�% �,���
Owner's
Map/Parcel# .5
Address
Lot#
Tele hune"d
Installer's Name 0'y111-7 `�.'-,�+��e.��.C"
Designer's Name,rRJ-
Address
A dt s „f'sit✓j stv/Cly ,rti;
Telephone# /�� 3
G"i ? ,j
Telepl)ot e#
Type of Building � 6 r.
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
Design Flow (min. required) gpd
Plan: Date 1�7--'p—o4" Nu4erc
Title
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
The um
further
Signed
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
design flow,5�-<T• T�j Design flow provided
/ Revision Date
of Sioil Evaluator
Date of Evaluation
agrees to tulftheabodescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
notnot t e the system in operation until a Certificate of Compliance has been issued by the Board of Health.
__ Date d
No. / COMMONWEALTH OF �'[l ASSAC14USETTS FEE t-
Board ofI-Iealth, MLA, MA.
CoTIEI�C�ATE F COMPLIANCE
Description of Work: ❑ Individual Component(s) QfComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (0, Abandoned ( )
by. l%s Ger` of �/J" is'7iG (�G�RdiGC"
has been installed in accordant with the provisions of 31p CMR 15.00 (Title 5) and the ap r ped design plans/as-built plans relating to
application No. ,dated — � Y/ Approved Design Flow �i pd)
Installer / rJ
Designer: % Inspector: Date:
The issuance of this permit sh I not be construed as a guarantee that the system will function as designed.
No. Cl ter f C� � � A!;; �� � ts.� � PCC
COMMONWEALTH SOF MASSAC44USETTS
Board ofIYealth, G Et =-/ AIA.
f
E
DISPOSAL SYSTEM CONSTRUCTION PRVIT
tr � X
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon (A) an indhidual sewage disposal system
at ca. -5— d.GC.'<.^tcd° J'% yam,
as described in the application for
Disposal System Construction Permit No. 6'1")' f0) -, dated l -22 6/
6
Provided: Construction shall be completed within three -years of the date of this permit. All local conditii ns must be met.
Form 1255 Aw.. 5rs5 A.M. smkln co. Boston, MA Date/ .21) ,�1413oard of Health