HomeMy WebLinkAboutApp-Permit-ComplianceNo. 7p- 2,1422
2(2 COMMONWEALTH Of MASSACIIUSETTS
Board of Health, �i n10 c �, MA.
APPLICATION E®R DISPOSAL SYSTLM CONSTRUCT]
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System
PERMIT20
20
HEALTFI DEPT
Location !'0ohgs /c.v
Owner's Name
Map/Parcel# `Qp
Address S
Lot#
Telephone# q ff gt^ tF 3
Installer's Name Ohs 6/ )7P/_S comsat
Designer's Name /�
Addressa3 Address
0/se"y y
Telephone
Telephone# S —
Type of Building //4-4,�, -
Dwelling - No. of Bedrooms 3
Other -Type of Building''
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date I �/ Number of sheets
Title /'�<-�� p_ .6s4�=a
Description of Soil(s) _.
Soil Evaluator Form No.
Name of Soil Evaluator
JAW
Lot Size sq. ft.
arbage grinder Wt�
No, of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
of Evaluation
I
DESCRIPTION OF REPAIRS OR ALTERATIONS velf Jt% ,-Y , v -r ,�
Vjq
The undersigned agree to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to tplac e.7 in o !'-- a Certificate of Compliance has been issued by the Board of Health.
y� r
Signed /.' f '7 �"' �''.� Date
Inspections �,C CiV c'e t C%tc f4 C'//!:j
No. ot,lx- --rz, -)- „f-1c2ad.,, FEE `ar kit -1
COMMONWEALTH Of MASSACHUSETTS'
Board of Health, A -AA l 0 t , MA.
I
CERTIFICATE OF COMPLIANCE
Description of Work:. El Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded1151 Abandoned
by: I ' a 1 N .i t"', , r`_
at f d
<f
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. ii!" C. !: dated :�I) r(. t t f �. Approved Design Flow >°`=-.' ( (gpd)
t
Installer
Designer:.r s.t�d r. •'" `• Inspector;t Date:-
.. t .. _.
The issuance of this permit shall not be construed as a guarantee thatthe system wrM function as designed.
No. rna,Ooi)�-.,wy.O-14,�`~i '+ .�, FEE ,Ft;:
COMMONWEALTH Of MASSACHUSETTS
Board (if Health, i /. t. M d 5 MA.
➢FISP®SAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( t) )Abandon( ) an individual sewage disposal system
at SwF .fi" .. 1 r", + ,,I ' C.
8 t; f r 1, ,rl "1 .�„ ' �"-1 .2 ,, , .��h :. x t" � -, as described in the application for
Disposal System Construction Permieo. ;/l ` i '`-(-` , dated + f •`' °= i % i''. l�
r
Provided: Construction shall be completed within three years of the date of this permit; All local conditions must be met.
Form 1255 flea. 5/95 F.M. SWhm Co. ChoeeMaen, MA Date i1 " Y Board of Health("-- � 4 �