HomeMy WebLinkAboutApp-Permit-ComplianceNo.�3gZ- THk COMMONWEALTH OF MASSACHUSETTS FEE '.5P°&ry
BOARD OF HEALTH ik gtI4
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APPLICATION FOR DISPOS L SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ()c) Repair ( ) Upgrade ( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Location Owners Name
Map/Parcel # Address
v(
Lot # Telephone #
n9lalle 's Name Desi ner' Name
G • l� r .�-
Adress Address
�i %117, , /.✓ � w ' }� S`�`46
Telephone # /l —0 Y Telephone #
Type of Building: �� �v �S� c!�_ Lot Size Sq. feet
Dwelling — No. of Bedrooms �.i Garbage Grinder ( )
Other — Type of Building No. of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow (min. required) gpd Calculated design flowgpd Design.flooVprovided gpd
Plan: Date 3- to _ � Number of sheets �_ Revision Date
Title * '_54 V&A -
Description of Soil(s) -qe
Soil Evaluator Form No. Name of Soil Evaluator _/Q - %•e-64 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 S and further agrees not to place the s stem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 9 - 2Z -
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
No.
Description of Work:
THE COMMONWEALTH OF MASSACHUSETTS
�&wtBOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) Complete System
FEE CL- [_)C%
(�� 16,11 �
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded-+), Abandoned ( )
by:
at 'J -
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. Z. dated 5 - 2 3'-W. . Approved Design Flow—(gpd)
Installer
-7Designer�'4Ad ���EZ� . Inspector _ ate fQ - 2` T �P
The issuance of this certificate shall not be construed as guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No� THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade S„ S) Abandon ( ) an individual sewage
disposal system at `�� 8 zb as described
in the application for Disposal System Construction Permit No.-'cj' dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Date '7-2:3-9E Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W" HOBBS& WARREN TM PUBLISHERS - BOSTON