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HomeMy WebLinkAboutApp-Permit-ComplianceZ, " 4a7le: COMMONWEALTH Of MASSACHUSETTS •� �` e'a'�"_r- � a 5"j ..r e Board of Hea�t'fi ° MA. IP.METC40ETIS' I AUG 0 5 2005 Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location Owner's Name /� ^ Map/Parcel# l./ o� Address aA44,t Ll�cif, Lot# 21 Telephone# Installer's Name 9, Ca lag -r- Designer's Name Address 'a© Iry K � 3 C.r Address Telephone# ,3 ,2 - 9'30 Telephone# Type of Building Dwelling - No. of Bedrooms. Other - Type of Building Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) Soil Evaluator Form No. gpd Calculated design flow Number of sheets DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a ee to not ;to ace a system in operation utnntil�a Certificate of Compliance has been issued by the Board of Health. Signed�s� �) ,fLe.-` •� i t ecc �J3 �+ Date f-� Inspections No. COMMONWEALTH � �T��rEm (T m � T ( FEE—So SETTS Board of Health, ��dU�` MA. C1 2l n Description of Work: LJ Individual Component(s) Ll Complete System � ' �✓ The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: L06 -r-1 s,�� at has been installed inaccordal e with th ro ��ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to applicationpNo.`_ 6 7 -2Q74 , /dated V� 01 . Approved Design Flow (gpd) Installer Po�u I & oug cc,) -a - _ j / Designer: Inspector: /,l A Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. �Z Board of Health. MA. 1: DISPOSAL SYSTECONSTRUCTION PERMIT Chi FEE " y zolu Permission is hereby granted to; Construct( ) Repair,() Upgrade ( ) Abandon ( ) an individual sewage disposal system at' as described in the application for Disposal System Construction Permit No.6"? dated (D (AQP 3 Provided: Construction shall be completed within thTee-feftrs of the date of this'per i -, All cajl condi ' ns must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health /