HomeMy WebLinkAboutMiscellaneous - 1423 SALEM STREET 4/30/2018 (112) No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
�OvM OF WCdn AOLvtr
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair ( ) Upgrade (v� Abandon ( ) - ❑Complete System Z"Individual Components
1�-Z3 Salem S4lej Mickat) a,14 G-614C rvlorgoll0
Location - �ner'sa� eMap 1aed z� `423 5a le ,) �
,Ai L4rAu1A
Map/Parcel# ` Address
Lot# r Telephone#
��v14d°c,iL �Nq➢neelj�A ASSOGiA-�
Installer's Name 23/5 "M DgYgner't Na{t� " MA
J t V Q s.l�V `y1y CJ7" 4X�
Address V Address
771- 3 OSO
Telephone# Telephone#
Type of Building: 4wi k &-kiii a Lot Size 44.01P 0 Sq.feet
Dwelling—No.of Bedrooms --rGarbage Grinder (h1 ) -ro & re,,ovccl
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required)310 gpd Calculated design flow A40 gpd Desi n flow provided A4o gpd
Plan: Date__1�1a]o2_ Number of sheets Z Revision Date I oZ
o� �e, Ossa
Title GCXA61 ) Sint&&—
Description of Soil(s)_ ce
Soil Evaluator Form No. Name of Soil Evaluator C, w e4 cO ds^ Date of Evaluation l l 21 of
DESCRIPTION OF REPAIRS OR ALTERATIONS Sc.e. .Pia►
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
Inspections
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
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No. THE COMMONWEALTH OF MASSACHUSETTS FEE
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System;Constructed( ),Repaired( ),Upgraded( ),Abandoned( )
by:
at
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. dated Approved Design Flow (gpd)
Installer
Designer: Inspector Date
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
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