HomeMy WebLinkAboutApp-Permit-ComplianceNo. ®/—/f� ree "i L'r V(J
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Board ofHealt/a,1146 ROUTE SO. YARMQ 28 M 1.
APPLICATION ,TDR DISPOSAL SYS, ��S 14UCTION HRMIT �
Application for a Permit to Construct( Repair( Upgrade (i1D Abandon O - ❑Complete System Uividuil Components
Location ' `
Owner's Name
® f�-
Map/Parcel# s!FQ
Address
Lot#
Telephone#
Installer's Name
ner's Name
-
Address 3®
Address-
Telephone# .—. ._ .2//
Telephone#
Type of Building a Lot Size sq. ft.
Dwelling -No. of Bedrooms F' S J Garbage grinder ( )
i
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures ,,.„,
Design Flow (min, required) ��A' Cl 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 a Mees not to place the system in operation t til a Certificate of Compliance has been issued by die Board of Health.
Signed �?T..?.G'�� llatc 7e3V-
Inspections S dQS Utile) 7AA7 e(e `ip $it, ` ,X, 7-v96't�
7 ewton
t /c,,� , J l e Pi . J -e O _-/
pt-, u..Y? eon S' 7 ° O F I— C, / ' D( v r1 ? t —� ( f - ,4 �
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No,
C�Ol�i�' O WEALTI-I OF 1MASSACIDUSETTS �( 7Z
BoardofHealth,��
CEI$TIFICATE O COMPLIANCE r 5. e e,�k AOLp
Description of Work: O',Individual Component(s) ❑ Complete System
r
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (t-)rAandoncd ( )
by:
at 1f /� s'1"r.` /i�, ``i.:.?.�za /' i, -.,..r ,..,..... ,.r-�r.M✓ l /f, l•"r_."�.
has been installed in accon
application No. 0 ' d "✓
Installer ! ',r."✓-rr"
Designer:"
The issuance of this permit
No. —U—el
Permission is hereby
at
with the provisions of 310 CMR1f.00 (Title 5) and do a roved design plans/as-built plans relating to
dated ,✓r"" ) - . Approved Design Flow m°" (gpd)
Inspector:
Date:
not be construed as a guarantee that the system will function as designed.
PEE /C�• '•"C
COMMONWEALTH DE MASSACHUSETTS G� �� �'`� �?
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Board of Health, �..-.,aY.- 6a! ^' ,NIA.I " f""� )F tl stn r-,; ..y.y �I
DISPOSAL SYSTEM CONSTRUCTION PERMIT
to; ConstrucC(_) Repair( ) Upgrade(y)Abandon( ) an individual sewage disposal system
_J
Provided:
as described in the application for
Disposal System Construction Permit No.-% i , dated %_. (0 _J
Provided: Construction shall be completed within Ch eeea�s�of the date of this permit. All local Condit op must be met.
Form 1255 Rev. 5/96 A M Sutkm Co. Bostort MA Date 7i 6-6 -/ Board of Health