HomeMy WebLinkAboutApp-Permit-Compliancea No.
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COMMONWEALTH Of MASSAC14USETTS 6,L)
Board o Health, Ys-'�R,%I
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APPLICATION FOR DISPO JCTION PERMIT
IT
ation for a Permit to Construct( ) Repair( ) Upgradek<Abandon()-,J2,C'omplete System ❑ Individual Components
Location C�� i/ /
Owner's Name
i
S V )ct 4 Ali
Map/Parcel# 3 9 2 201
Address
'
P,i% 14 V /NWw
Lot# / 9
Telephone#
9P/7 -- L
Installer's Name G I
Designer's Name
4 /e
Address / I % vi
Address .7 Z _r
"11,4 1 A,�
Telephone# _Co g _ Z �v D � Z
Telephone# S� _ f'�Z -Z
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 3-74) gpd Calculated design flow
Plan: Date SS -9 vy 6 Number of sheets 11
sq. ft.
' Garbage grinder ( )
o. of persons Showers ( ), Cafeteria ( )
Design flow provided ��y gpd
Revision Date
Title
Description of Soil(s) fG"2_ 6�/�i bol -y-
Soil Evaluator Form No. Name of Soil Evaluator _S A 41 f 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 agrees to not to ace the syssttey-in operation until a Certificate of Compliance has been issued by the Board of Health.
x Signed Li ��/" "' �f Date
Inspections
No. OV/ ` TS/.ter ,Br,� �EE
COMM®NWEALT14®f MASSAC14USETTS
Board of Health, G MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) VC/omplete System
The undersigned hereby certify that th +Sewage Disp sal System; Constructed (v , Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at G// / /o vE'r Rd _ !N, JA✓ M a� Ci
has been installed i ac rda e with the provisions of 3P CMR 15.00 (Title 5) and e proved design plans/as-built plans relating to
application No. dated �U j".� a Approved Design Flow � (gpd)
Installer M" E' jam'
Designer: t4 S /(— Inspector: X_
The issuance of this permit shall not be construed as a guarantee
Date: !,Z' J z/6
the system will function as designed.
No.
C®MMONWEALT14 Of MASSAMBUS ETTS
Board of Health, ktY , MA.
DISPOSAL SYSTEM CONSTRUCTION CTIO1V PERMIT
- � FEE_.
Wr'?I�' �
Permission is hereby granted to; Construct( Repair( ) Upgrade( )[ Abandon( ) an individual sewage disposal system
ra/
at Gil G 1aVe'wl, I �4C/_1)1 7G / as described in the application for
Disposal System Construction Permit No. -)6 - , dated /
6uwjS
Provided: Construction shall be completed within dn=gMs of the date of this er ; it- I local conditioas must be met.
Form 1255 Rev. 5/96 A.M. Salkin Co. Boston, MA Date %(/ --} --,7 61 LBoard of Health