HomeMy WebLinkAboutApp-Permit-ComplianceNo. D / / 1f0 FEE �V ` V V
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Board of Healt�'QH DEQ
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I 14 F (. a hE'.'. 28
APPLICATION FOR DISPWbAL�-,I,.Y'994,'�kM.9TRUCTION PERMIT
Application for a Permit to Construct(41Repair( ) Upgrade( ) Abandon() 2/Complete System 01 dividual Components
Location 77 If ew A&Owner's
Name
/-/0 C'ewj l- zj
Map/Parcel# l a ;_75 Z.
Address
Lot#
Telephone#
Installer's Name g��'' � C��vr. �'"
Designer's Name
eb" & e �iLOLo�i
Address � �Je�� p
Address
�-- ���l��r
Telephone#
Telephone#
— ,J
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
e_5;ia a#c
No. of persons
Lot Size 245,1� 7 sq. ft.
Garbage grinder
Showers ( ), Cafeteria ( )
Other Fixtures l`
Design Flow (min. re uired �'Z gpd Calculated design flow �� Design flow provided 7 gpd
Plan: Date 2 e Number of sheets % Revision Date
Title S c%r //C4lGYff !1 }� lel > CLXI21&/- t
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton �to�Ie em in operation until a Certificate of Compliance bas been issued by the Board of Health.
Signed Date
Inspections U( -AA,`
No. CJb FEE
COMMONWEALTH OF MASSAC14USETTS N
Board of Health, MA.
CERTIFICATE OF COMPLIANCE _ /
Description of Work: C] Individual Component(s) efComplete System t / r r `� u ` r .
The unders'gned hereb cer th he Sewage Disposal System; Constructed (/Repaired ( ), Upgraded ( ), Abandoned ( )
I --
has been installed in accor n e with the rovisiions of 310 CMR 15.00 (Title 5) and h proved design plans/as-built plans relating to
application No. - / , dated ! `� Approved Design Flow 7-7 (gpd)
r
Installer %i/7,(�
Designer: X)97,0 / (29jaw tA/xw. Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE 'eTJ )Z
COMMONWEALTH Of MASSACHUSETTS 76
Board of Health,
�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissio/n� is hereby granted
.. to; Construct(v< Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at �J Cf% / c as described in the application for
Disposal System Construction Permit No. 05' 6 , dated 5' S
Provided: Construction shall be completed within rs of the date of this p�'riiit. V. local conditio must be met.
Form 1255 Rev. 5//96 A.M. Sulkin Co. Bosto?, Date '5 " '�-O Board of Health