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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 99- � 7a COMMONWEALTH OF MASSACHUSETTS Board of Health, �r/�%®�.��/ MA. FEE _�;b I� 6 ����v Y� APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT (✓) Application for a Permit to Construct( ) RepairUpgrade( ) Abandon( ) - ll� _/Complete System ❑ Individual Components Location Owner's Name Map/Parcel# % Afi~ 127��`� r � Address Lot# y 3 2-51 Telephone# Installer's Name �Q rG� ���;7­ Designer's Name Address 77, Q 6 �/ ` Address Telephone# Telephone#�g � -7 7/2 Type of Building /'( egIaF(ai r!`e Lot Size sq. ft. Dwelling - No. of Bedrooms 7 Garbage grinder 4-2,7 Other - Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 3J�d gpd Calculated design flow IIfd Design flow provided 37 gpd Plan: Date 13 %3/�I9 Number of sheets ! Revision Date Title 5/ /-Z!,- <5 ��9� 2 m, v _ _ Description of Soil (s) _ Soil Evaluator Form No. :DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and ffirther agrees to o pi a the system in operation until a Certificate of Compli ce has been issued by the Board of Health. Signed Date �2 Inspections No. W– FEE C®MM®NWLA1111 OF MASSAC14USETTS Board of Health,�d Y�r�ro�.r, MA.i CERTIVE ®F COMPLIANCE Description of Work: LlIndividual Component(s) plete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 04pgraded ( ), Abandoned ( ) by:G!/ItIC-1747--4 at 5 -6 7 - has been installed -in accordance with the provisions of 10 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to,, application No. / dated (or " /Approved Design Flow (gpd) Installer 'eR!3/a, e, G / i Designer: %} - --W �/lf�//(� Inspector: J L Date: _ The issuance of this permit shall not be construed as a guarantee that the system will ction as designed. COMMONWEALTH OF MASSACHUSETTS Board of Health,lr/rii©�%` MA. Permission is hereby gr2 at6 �l�r DISPOSAL SYSTEM CONSTRUCTION PERMIT to; Construct( ) �w/ * ' e, - -_- FEE yd Repair (V/) Upgrade( ) Abandon( ) an individual sewage disposal system Disposal System Construction Permit No. —> V, dated b as described in the application for Provided: Construction shall be completed within three years of the date of this permit. All local conditions /must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date V S-- Board of HealthC./GY!