HomeMy WebLinkAboutApp-Permit-Compliance�--
No. eo -55� I /C,E, /� '// FEE
COMMONWEALTH OF MASSAC14USETTS
ARM®UTH HEALTH DEPT
Board of Healthy 146 ROUTE 28 MA.
APPLICATION FOP, DISPMATA9"VWMIRMUCTION PERMIT
Application for a Permit to Construct( ) RepairVKUpgrade() Abandon() - ❑ Complete System 4ffIndividual Components
Location 3a co c toS rd- 1A
Owner's Name f` % y - ~�
Map/Parcel# s s T/
Address
Lot# if iT /��-�7i(J
Telephone#
Installer's Name ✓ //I ` (�
Designer's Name
Address /'nor
Address I oY /0 4.4
Telephone#
Telephone# SO8- 3999'--9
Type of Building �l'1/`e �i�i Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures ,,
Design Flow (min. required) �r/V gpd Calculated design flow 3-3D Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) cSre Sc,,'j %6E
v
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I e 10 &11-e, C /Jl'
The undersigned agreyqo install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n9Ao pl ce the tem ' o er ' until a Certificate of Compliance has been issued by the Board of Health.
Signed Date '0". — 41:>
1 ispections
No. Cil/ ( y FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: a Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded {Abandoned ( )
by:
at -3 a C f, C i
e
has been installed in accordan withV the provisions of 310 &R'15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 010- dated Approved Design Flow(gpd)
Installer i,:-
Designer:
;
Designer: C Q. 1, ( ',] • S-A z l Inspector: _
- - 17 - - --
Date: a- g
A the system willfunctionas designed.
C®MMONWEAL114 Of MASSACHUSETTS
Board of Health., �� !� c �� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby/granted to; Construct(
at ? /C�!/
FEE
Repair- Upgrade ( ) Abandon ( ) an individual sewage disposal system
as described in the application for
Disposal System Construction P44 No. dated fl -1-3 -
Provided: Construction shall be completed withis�ofthe date of this permit. All local conditions ustbe met. i
Form 1255 Rev. 5/96 A.M. Sulkin Go, Boston, MA Date l/7� G� Board of Health