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HomeMy WebLinkAboutApp-Permit-Compliancer COMMONWEALT14®F MASSAC14USETTS Board of Health,YAH116OUTH HEALTH DWK APPLICATION FOR DISP=W&&MiQ*CUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 4O /S Owner's Name G Map/Parcel# 04 Aa-�[, Address P- 0 � 13C .11) R ,, - S L6 Lot# 19Telephone# 5-O8 3 —,044Z Installer's Name P K. Designer's Name Z 6„ Address IE S Address S� E - Telephone# 6D$ .365%59 f3 Telephone# Type of Building Lot Size /,ZZ� l0 7 7 sq. ft. Dwelling - No. of Bedrooms Garbage grinder (JPO Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) (p L Q gpd Calculated design flow /a �o Plan: Date 49196101 Number of sheets 0 A /-- Title PjabAoSE'b' SEaT/G-,DE,S/6A� Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Design flow provided 46494 gpd Revision Date Name of Soil Evaluator 7.Jf}/6D40AWL%Date of Evaluation The undr 'eed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ttd&ce hein operation until a Certificate ofCompliance has been issued by the Board of health. Signed Date Inspections No. ©�—(` FEE Board of Health, ./ilt /lf MA. CERTIFICATE OF COMPLIANCE Description of Work: 0 Individual Component(s) Complete System The undersiWd hereby certify that the Sewage Disposal System; Constructed ( , Repaired ( ), Upgraded ( ), Abandoned O by: JJ� iz/J//f at �% f (`i ✓t 7t //Ll/ has been installed in cco'da ce with the rovis1ions oo 1310 CMR 15.00 (Title 5) a t)�}o approved design-plans/as-built' plans relating to application No. � �� dated =�/ _�/ Approved Design Flov LG' (gpd) Installer Designer: // �Jr LG A<i� Inspector: X"114/.1:Date: 1 2- The issuance of this permit shall not be construed as;'a r antee t�a. the system will function as designed. No. A l ' r "�� �� FEE COMMONWEALTH OF MASSACHUSETTS n� <�� 1-7) Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted, to; Construct( 21- 9- dl- /i 1!/ col'q�All --j Repair( ) Upgrade( ) Abandon( ) an individual sewagWidisposal system l as described in the application for Disposal System Construction Permit No. L.(/,dated Provided: Construction shall be completed within vols off the date of this mit. All local conditi s must be met. lth Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 7--)I-dl Board of Hea