HomeMy WebLinkAboutApp-Permit-ComplianceNo. lO��
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C®MMONWFALT14 Of MASSAC14USETTS
Board of Health, 4AiZMp0TA , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair>< Upgrade( ) Abandon( - Complete System ❑ Individual Components
Location 185-FANat
Owner's Name
Map/Parcel# M Q �� q
Address
' 1�
Lot#
Telephone#
CT D&o4v
Installer's Name 5
Designer's Name
Address - IveA
Address XFix
Telephone# D`Q _ _ 10
Telephone# ()+9<0
Type of Building Si,C .n �; d l Lot Size O V__ sq. ft.
Dwelling - No. of Bedrooms ( EOU92) Garbage grinder VVIR_
Other - Type of Building N 6 f1Q No. of persons o�_ Showers (tlj Cafeteria ( Gy
Other Fixtures LcgC Q: cM n rkjz-%
Design Flow (min. required) "')'gpd Calculated design flow `-'4 y'Q V
Plan: Date 1S `M Number off sheets
Title Zt -; M�osp_A 54 Pe C
Design flow provided gpd
Revision Date
it
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Y Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS `' '� `•'tel �Y'l`LS�� Q1�C>
r
The and signed grees to ins above described Individual Sewage Disp sal System in accordance with the provisions of TITLE 5 and
further t t� (ace ation until a Certificate o f ;an has been issued by the Board of Health.
Signe Date / U
Inspections
L
No.0 2. - G FEE
COMMON�� OF MASSAC14USETTS
Board of Health, ' all ,n (1" , MA.
CEPTIFICA E Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 9l'"Complete System
The undersigned hereby certify that�the Se age Disp sal System- Constructed ( ), Repaired ( ), Upgraded (�j}, Abandoned( )
by:.5 12!) t -I
ate t 11 l/�( f r,( l Yl'1
has been installed loaccorda ce with the provisions of 310 CMR 15.00 (Title 5) and th roved design plans/as-built plans relating to
application o. F/ i dated %! H d �pproved Design Flow �� / / (gpd)
Installer
Designer: Inspector: Date: 11-26 �0 Z_
The issuance of this permit shallnot be construed as a guar tee th t the system will function as designed.
No. 102- 5 FEE L /
C®MMONWELAl[ OF MASSACHUSETTS
Board of Health, ( /T)( f~; MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;Construct( ) Repair(/ Upgrade( ) Abandon( ) an individual sewage disposal system
ate) �a. r / t (.�) _ �1 ` r; VYl as described in the application for
Disposal System Construction Permit No. 62_1� dated 8--)/'&
Provided: Construction shall be completed within t_ P
hro he date of this permit. All I cal. conditions mu be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date/ Board of Health