HomeMy WebLinkAboutApp-Permit-ComplianceNo. / /. oovue:LT FEC ,'7C/• 6'YJ
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth, �xenl ) e) -f 14 ASA. ,�,Jt'i ✓
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(V Upgrade( ) Abandon( ) - 0 Complete System 0Individual Components
Location 3 " C
Owner's Name f, � til
. Map/Parcel#
Address �I i t p -n4
Lot# 30
Telephone#
Installer's Name S zip
Designer's Name C e—AlA//126 ME�
Address 1La-t
Address _Af +17
Telephone# _I�
Telephone# ? 7
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required
Plan: Date11119-7/
wl
Title - V t
Description of Soil (s)
Soil Evaluator Form No.
33c) gpd
Calculated design flow .33
' I
T)F3(TRTPTT()N(IFRRPATRSnRATTF.RATTON..' 'Pe—le �0I/9fJ
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided S� gpd
Revision Date
Date of Evaluation
The undo i e grees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further'a o not t [a a systemn oau peruntil a Certificate of mpliance has been issued by the Board of Health.
"Signed ,fiA sdll Date 197
14
'inspections
No. FEE '5V- eD
COMMONWEALTH OF �'[l ASSAC14USETTS
/ A /
Board of Health,� °� %%? , MA. OA �
CERTIFICATE OF CSO PLIANCY
Description of Work: 0 Individual Component(s) AComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgracledAbandoned O
at J
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 7-2 ` J/ , dated i'-16-9° 1. Approved Design Flow (gpd)
Installer — &o % rg
Designer: .00410 07s,/ Inspect -: :�.R%E' t":: '� Date: