HomeMy WebLinkAboutApp-Permit-ComplianceNo. B O M"vG^Zb-Zsl �v FEE 100
20 — O rl COMMONWEALTH OF MASSACHUSETTS (YOW10I 4 T
D009 WbL Board of Health, IGMQI A�h , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System Q Individual Components
Location ao
Owner's Name 1 G el
Map/Parcel#
033.1 01
Address 12 a OrN gszk
Lot#
Telephone#
Installer's Name 4,
Cava. 1 O
Designer's Name
Address 1 c eo
e5'�e%v.� G.
Address
Telephone#
lk
Type of Building Rcsinket--at os Lot Size sq. ft.
Dwelling -No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OFREPAIR.SORAITERATIONS �- 1470.D GOX e)OL-Y !!
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to �not� $to place t)te system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r,_t �.+ 2!, Date 2-Zo• ZO
Inspections
No. X1-1 )�' C�'"'7.c'l FEE BJ,55-E:10
COMMONWEALTH OF MASSACHUSETTS
Board of feallh, )aS ry vrr, ra% :� MA.
CERTIF ICATI E,�OF COMPLIANCE e o���9v�
Description of Work: O'lndEl Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ,Re aired (^^)*
Upgraded O,Abandoned O
at VZ 01,A�'�^ da�
has been installed in/ accordance with the provisionslof 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. ii " � '� dated - i t 12 tApproved Design Flow (gpd)
Installer ( (^i '-Yi 0.1_Iw ,^-n..., i<t�(.� "'F` C"1ta`c"I
Designer: htspecton.",A
Thr issunncr of this nrrmit shall not he cnnstrned as n mnnrnntne
system will function as desimied.