HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALT14 Of MASSAC14US ETTS
Board of Health, i4Q V% Oy%1* , MA. /
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair • Upgrade( ) Abandon( ) - ❑ Complete System,�*dividual Components
Location - r, l.l"Tl�lN
Owner's Name ` rj
Map/Parcel#
Address
Lot# --op 3
Telephone#
Installer's Name D -
Designer's Name
Address .
Addres", �\,0� _� 16
Telephone#
Telephone# 5 14 IS - C)-.+g�a b
'Type of Building c S \G\QnA�,.\ Lot Size j 02.1 %-o OCA sq. ft.
Dwelling - No. of Bedrooms \ gx[ -Vk s -n r l(o — ��P_S1 C� n Garbage grinder (1%)
Other - Type of Building alL No. of persons C'Z Showers (e, Cafeteria (Vf
Other Fixtures L-aut4T0 (L`C b V ►� Ir.e� I-
l�
Design Flow (min. required) ��a gpd Calculated design flow
Plan: Date o1 \ 8Number of sheets
Title \` r�;6M5X\ C `tea
Design flow provided gpd
Revision Date
—_ —A— i1
Description of Soil (s) t�QR QT CC'IC�� ' V
Soil Evaluator Form No. J\ e a Name of Soil Evaluator i
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS p G.1K\*KGC`0Q c\ : .' Osp-A r:A cxn .
The unde igned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to no to place tem ' o ation until a Certificate of omp 'ante has been issued by the Board of Health.
Signed
Inspections
No. r, ' �' aj
COMMONWEALT14®f MASSAC14US ETTS FEE � L'�
d` (f1� #7
Board of Health, = j � � � t�I 167 ��. f f y- � MA. Ij
CERTIFICATE OF COMPLIANCE d,�s�
Description of Work: Individual Component(s) ❑ Complete System
The undersurned herebycertify that the Sewage Disposal System; Constructed ( ), Repaired ( „Upgraded ( ), Abandoned ( )
by: °7 T t ✓ f` A
at s... . l Y G �/"c }
has been installed inaccor4ance with the prow 'ons�oj� 310 CMR 15.00 (Tale 5) and the a proved design plans/as-built plans relating to
application o. G �, ,dated Approved Design Flow 3 l (gpd) 2 Ile Wl /�T�d'//•3Pj-
Installer r i l / ` `f /f ' i 1 /7
Designer: (�Gtyl 7 c7!%'!/-�f /� l�'f�' . Inspector: ` z Date:
The issuance of this permit shall not be construed as a guarantee that the system will f ction as designed.
COMMONWEALTH OF MA$SACIIUSETTS
Board of Health, (..Lf� �,�l, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE U G
14 71
Permission is hereby granted to;, Construct( Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 1� ' 1 "i,� E A` ('V v5r' 3/i as described in the application for
Disposal SystemiConstruction Permit No. ated
Provided: Construction shall be completed within `fli�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/C, ` �/�