HomeMy WebLinkAboutApp-Permit-ComplianceNo. PEI: '5V " t/
COMMON EALIM. !a Iq fI�IUSETTS r�<fcL� 1r
%a �Th1 DEPT.
Board of Health, 1M ROUTE 28 , MA.
O.'A ' IA
I�1�LIC TIt➢ T FDIC DISPOSAL SYSTL �I mall ]tC�11 p �1�YIIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location G
E,t/Cp �--" t /j G
Owners Name (�'
Map/Parcel#
�Z 4- �-
Address
Lot#
Telephone#
Installer's Name
S
'
Designer's Name. 7;�21eD//
Address
--
Address `L -
Tclephone4k
Telephone#
Type of Building r L.ot Size sq. ft.
Dwelling -No. of Bedrooms �`h'!�i%r .'�- Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Plow (min. reggqtired) 3.3 gpd Calculated design flow 33 0 Design flow provided -345_/ gpd
Plan: Date 63 Numberof sheets I O"F Revision Date
Title O E E G tc ,J/ L
Description of Soil (s) 3 F E_ f Lj!t?y— 72k
Soil Evaluator Form No. 2, 709 Name of Soil Evaluator-.l� l//I1 /3`lr' Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS gh PLbLF 4riwx
The and r igned agrees to in B the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ees to t t p ce d sy. tperation until a Certificate gf-Comp ce ))a. n n issued by the Board of Health.
Signed Date � ���
Inspections
COMMONWEALTH OF MASSs_I4USETTS
Board of Health, Qfrner�,tT1'1 , NIA.
CERTIFICA E OF COMPLI ,r NCS
PEE
do C)f
p e k 10
Description of Work: O Individual Components) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: .. ) (, `v'.r, p`. i t,rt 1 e"r- �1 S7 .
at �1 d`�*y'9, (ren �a 1 Y- t r (. 14
has been installer in accorda)ice with thefprovisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application N(. si' f % dated :1 . Approved Design Plow-' gpd)
Installer F/ 1 G'' "r- " ors Cco '" � „//i
Designer: ll 6 C.ii Inspector: �,r''�..�P..�,.J�LI,zk°r° d < Date:
The issuance ofthispermit shall not be construed as a guarantee<th�system
t,will function as designed.
No. !'2� -"f (6 t"' r - /7 ..�''dc'v" -?' PEI:
COLI `! ONWEALTI1 OF MASSA IIUS-ETTS
Board of Health, o G , ) NIA.
DISPOSAL SYSTEM CONSTRUCTION P -DI f IT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an,idividual sewage disposal system
at l C) If -rr 1 Cir r"i .S r 1 as described in the application for
Disposal System Construction Permit No. dated (� .
tFL
Provided: Construction shall be completed within d -c rs of the date of this permit All local )conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date & Board of Health