HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0*'-- FEE 106
®MM®NWARMOUTH HEALTH DEPTTS
Board of Health, 1146 ROUTE 28 , MA.
APPLICATION FOP, DISPO L M?R'MAMJCTI®N PERMIT
Application for a Permit to Construct(VRepair( ) Upgrade( ) Abandon( ) - CR/Complete System ❑ Individual Components
Location /5—�,r �`
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name r �® , d
Designer's Name �� 5(ln e
Address 415`—
Address ZJ
Telephone#Telephone#
Type of Building/Lrr����j���i Lot Size Ad 49d sq. ft.
Dwelling - No. of Bedrooms J Garbage grinder (40
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ZZ -a gpd Calculated design flow 3 36) Design flow provided 3 y0 pd
umber _ _ �/ G� w�13
Plan: Date 7!-1 Z/ >
Title si Q' 7 �N�' f sheets 1 5— (—e -Lc, -V5 Revision Date C�' y /2�2/
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator 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 to lace a cyst m in operation until a Certificate of Compliance 1 s been issued by the Board of Health.
Signed Date Z
Inspections
No. O 1-1 ' "! M
COMMONWEALTH OF MASSACHUSETTS
Board of Health, / -PI/ W2�Z,6 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (v),/Repaired ( ), Upgraded ( ), Ab-,
by:
at
FEE 16
has been installed in accordance with the provVionk of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. r'i �'L0 dated •�%a G L Approved Design Flow 3 yo (gpd)
Installer
Designer: p
jt./ t U `, ector: r—^ Date: �
�`'' Ins
The issuance of this permit shall not be construed as a guarantee that the system unction as designed.
No. Q 14 1 FEE U G
COMMONWEALTH OF MASSACHUSETTS d -Q
% cdc Y332
Board of Health, ���i�%®1���? MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIJIPjk
Permission is hereby granted to; Constru t( tRepair ( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. eD14' �'' dated �• '� Cl y
Provided: Construction shall be completed within three years of the date of 's pe m t. AA local con ttions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1 O `( Board of Health