Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. O �i �O THE COMMONWEALTH OF MASSACHUSETTS FEE (3(1,. 60 t3D, 7d //IISP BOARD OF HEALTH OF l�.l�A�1/d ¢ opt✓/ Gr APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair ( ) Upgrade (�Q) Abandon ( ) - ,] Complete System ❑ Individual Components a Locatio 57 % 33 Atm lap/1rcel #/� 3A Lot # Owner's Name 1? -.3 4Z& W W,, f7' c7- s y I -. Add ss Type of Building: a 3l e14A,-U Dwelling — No. of Bedrooms log` Other — Type of Building No. of persons Other fixtures Telephone# Designer's Name Address/ Telephone # Lot Size 1-1O I Sq. feet Garbage Grinder ( ) Showers ( ), Cafeteria ( ) Design Flow (min. required) Jf�/ gpd Calculated design flow 53'0 gpd Desi flow provided 536 gpd Plan: Date / Number of sheets Revision Date Title �'`of)i Description of Soil(s) _ �f -� Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS = Date of Evaluation /3 0 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 3 - Z!7 — d f FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ----..-- --- --- - - - - - - - - - - -----------�_- No. THE COMMONWEALTH OF MASSACHUSETTS FEE'S off% _ BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Work: E]Individual Component(s) E]Complete System ftt S 7,1 C.,. The undersigned hereby certify that the Sewage Disposal System; 9-Q.nstr -by: at A 15 J 47 has been installed in accordance with th pYd—V106ns of 31.© &R ; plans relating to application No. ,d dated — " , '00% ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) Ab ) and the approved design plans/ built Approved Design Flow (gpd) Installer k Designer:_ /�7,li�C/ �i?`d�L` Inspector � �J� � Date �G� The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 a No. _L12/D THE COMMONWEALTH OF MASSACHUSETTS FEES BOARD OF HEALTH((��''G DISPOSAL SYSTEM CONSTRUCTION PERMIT # Permission is hereby granted to Construct ( X ) Repair.,.-()() Upgrade ('°`) Abandon ( ) an individual sewage disposal system atI2— (ad IZ�.�,� ��^" �/ as described in the application for Disposal System ConstructionPermit.No.l dated 5..- Provided: Construction shall be completed within t� of the date of this permit. Al ocal conditions must be met. Date —'� �� Board of Health FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM -1255.(REV 5/96) H&W HOBBS&WARRENT" PUBLISHERS - BOSTON 7`