HomeMy WebLinkAboutApp-Permit-Compliancel -t YL, c�! ,�-�1
No.. THE COMMONWEALTH OF MASSACHUSETTS FEE Ji uCJ
BOARD OF HEALTH'2—
OF
/APPLICATION FOR DISPOSA YSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Type of Building: 46
Dwelling—No. of Bedrooms
Other—Type of Building _
Other fixtures
of persons
nder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. 'eqt,.red) 33a gpd Calculated desigp flow,5 ' rd gpd Design f�vided � gpd
Plan: Date D Nunjber of sheets / Revision Date
Title / /q7[ -5- So- _
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 ogre of to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections a°— a>O - J/ //S ®1
FORM t -APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No. f)-/ _. (` THE COMMONWEALTH OF MASSACHUSETTS FEC C`!7
�!c7Fi!"'_I BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE r 4acl
�l7 c
Description of Work: E] Individual Component(s) .Q"'G`omplete System - (.�'� ,f/'t� f' '��`"� /"/-?4
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(" ), Abandoned ( )
by &Z L / oA
atj
has been installed in accordance with the pfovislons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No.60 ',-a % dated / 5 " /` /J74 . Approved Design Flow ) (gpd)
Installer d' I I i J 0 " I"C" )1-q r ` f C. 0,)
Designer: - "i..:. ,1 t`< "o—/ w Inspector..A ff I'V
The issuance of this certificate shall not be construed as a guaran ee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. 1_. S J'`j- THE COMMONWEALTH OF MASSACHUSETTS FEE
rg BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted [o Construct ( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at f F 1 J) -5 / i_-�9'`M''=,."-�,r=-✓`:F=z »,'7 as described
in thea application for Disposal System Construction Permit No. 1,Z. - -_-/ :r"
PP P Y � ,dated
Provided: Construction shall be completed within -throe -years of'tbc date of this permit.,f�ll local conditions must be met.
Date ` / - C�G� Board of Health ; �. Il of %�
FORM 2 - DSCP DEP APPROVED FORM 5/96 �`� I/
FORM 1255 1REV 5/96) .• ' 1-I&W Hoess& WARREN'" PUBLISHERS - BOSTON
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