HomeMy WebLinkAboutApp-Permit-ComplianceNo. d T a7 3 FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, 1143 Rs rE no , tp
APPLICATION FOR DISPOSAI�?VM�ffO"RWTION PERMIT
Application for a Permit to ConstrucWRepair() Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location
3o LmwAw, Pj J$
Owner's Name
Map/Parcel#
7
Address 3 (� ( m p y) �-i f Sy�,,j�
Lot#
Telephone#
Installer's Name
C t 2S (.
Designer's Name
Address
_v . &,y -2 C0 3 CSN ui�C /
Address
Telephone#
J 2.9 '/v2$
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
Name of Soil Evaluator
No. of persons
DESCRIPTION OF REPAIRS OR ALTERATIONS /1. P,�i / a Fes:
&Je-a-e+
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
cINti IS dcC-(<- 1 -' " ,1 - ) // _c- -
The undersigned agrees to install the above described IInndividIal Sewage Dispos ystem in accordance with the provisions of TITLE 5 and
further agrees to not V3Lplace the system in operation a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
Vt
FEES
COMM®NVVjk� f �14US ETTS � �tk
ry 1 U `7p
Board of Health, MA. f
EI
Description of Work: AJndividual Component s) In
The undersigned hereby certify that the Sewage Disposal System;%'-06
nstructedy), Repaired ( ), Upgraded ( ), Abandoned ( )
by: C r,. ill �� 5C L L -J
at 3b L `1 *\. ✓�
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 03- 17 date Approved Design Flow (gpd)
Installer ' ✓��SeS
Designer: Inspector: Date: �/ d
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.G d" / FEE
Board of Health, �"� �'� MA. ^ G
DISPOSAL SYSTEM CONSTRUCTION PERMIT y
Permission is hereby granted to; ConstructK.J_ Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at e� L`� V),A"n vt S as described in the application for
Disposal System Construction Permit No� -� 7 dated 0-1-0
Provided: Construction shall be completed within, three years of the date of this erirnit. All local nditions must be met.
a
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date A/ U Board of Health