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HomeMy WebLinkAboutApp-Permit-ComplianceK No. 7� —/(06 THE COMMONWEALTH OF MASSACHUSETTS FEE SV-6_�Z) 9 BOARD OF HEALTH OF APPLICATION FOR DISPOSALS STEM CONSTRUCTION PE (�.� IT Application for a Permit to Construct( ) Repair ( ) Upgrade tion o .Cd Map/P eel # of # —. Installer~ Name 3 / 24S S7 7 Address Telephone # Abandon( ) - [:]Complete System ❑ Individual Components /YM)m plcan-1 ,sN oVGr� +J I;JSy 73 4�e—1 ncr's Namc �( 3 y , Li 3 )ess l Telephone # Address Type of Building: �� ld� f. -Z__ t Lot Size VI cl Zo Sq. feet Dwelling — No. of Bedrooms Garbage Grinder ( ) Other — Type of Building — No. of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow (min. required) 6 a gpd Plan: Date Nu Calculated design flowiK� gpd Description of Soil(s) Ci`oi og@w�.. Soil Evaluator Form No. i Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS Design S -B gpd The undersign gr t nstall ov described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fu r no ace. y in operation until a Certificate of Compliance has been i ued b the Board of Health. Signed Date 3d P Inspections FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. % THE COMMONWEALTH OF MASSACHUSETTS FEE Sri. Ud/ BOARD OF HEALTH CE TIFICATE F COMPLIANCE ©� C Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: VDO Clr)� s.iC- at IS KaLz Com it2Iy% has been installed in accordance with the Drovisions of 310 CMR 15.00 (Title 5) and the approved design pla s/as-built plans relatingto app 'cation No. dated " 'r pproved Design Flow d) Installer i I , Designer: 161y:/A,%Inspector q Dae The issuance of this certificate shall not be construed as a guarantee that the system will function as hesigned. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No. ?,f /(0G THE COMMONWEALTH OF MASSACHUSETTS FEE I—sy•� .�- BOARD OF HEALTH DISPOSA SYSTEM CONSTRUCTION PERMIT Permission is hereb gr n ed to Construct Re ( ) Upgrade ( )-Abandon ( ) an individual sewage disposal system at % aw- CAS izd�P 1 j D- /���nyvvoVfl., as described in the application for Disposal System Construction Permit No. /6" '/6 4, , dated J� '"�. Provided: Construction shall be completed within three years of the date of this permit. All local cond`itions�mustbe . Date6 Board of Health L��04,00, FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W HOBBS&WARREN TM PUBLISHERS- BOSTON