HomeMy WebLinkAboutApp-Permit-ComplianceNo. O, (�['�
FEE
COMMONWEALTH OF MASSAC14USETTS
fl Board ofHealth, g19Q.ha0J-�ln
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
ON\TR CTION
PERMIT
Application for a Permit to Construct(,<Repair( ) Upgrade( ) Abandon( ) - O Complete System ❑ Individual Components
Location 2 q-7 211 f4
!�& . fi j, rh ,
Owner's Name fflu Sfz
Map/Parcel# s'3
O
Address 3V novyv �
Lot#
Telephone#
Installer's Name �,f
Designer's Name
Address 35b rn,9. rj S+
w y1vin o h
Address
Telephone# 08, - 77S- 29'00
Telephone#
cc -5)
Type of Building LA, P le- %< Lot Size sq. ft.
Dwelling - No. of Bedrooms jpt 2 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS i rV C h KI rye t '1� bn^i � S d� 6V I . tnlq
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to not to plac syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. vq COMMONV'V' ir.t LT14 Of MASSACHUSETTS FEE � t
Board of Health, A4-14-2.. MA.
CERTIFICATE OF COMPLIANCE
Description of Work: IF-hidividual Component(s) ❑ Complete System_
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ('Upgraded ( ), Abandoned ( )
by:�C (�
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated S �_ Approved Design Flow (gpd)
Installer11-1
Designer: �— Inspector: al il4w Date: ` 7
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. (a / �_'' '-r G v FEE 1 s
COMMONWEALTH OF MASSACHUSETTS
- Board of Health, C��-'/l� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair) Upgrade( ) Abandon( ) an individual sewage disposal system
at 2 q 7 I 0/7/w/--"' Y- as described in the application for
Disposal System Construction Permit No. -3 ~IS dated 6 O
Provided: Construction shall be completed within of the date of this permit. Alllocal
llloccaall conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date - 0 3 Board of Health __/�[�