HomeMy WebLinkAboutApp-Permit-ComplianceNo. . FEE
VIV
Board of Health, 11 ` S ROUTE 23 MA.
SO
YAR 9, i-€, h3.'
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location STR6Er
Owner's Name 9 ff
Map/Parcel# 109
Address
Lot#
Telephone#
Installer's Name
Designer's Name COW- WD EA)61x)E60�6,
Address DX E Al 13
Address
Telephone#
Telephone#
i
Other Fixtures ��lkg4t -91
T
Design Flow (min. required) A-Ogpd Cal ulated design
Plan: Date Dr -C, 15-, I)OL Number of sheets
Lot Size o)o / sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
iS = 3
/64 Design flow provided gpd
Revision Date Z
Title
Description of Soil (s) Lol3i7i Y� nn ,
Soil Evaluator Form No. Name of Soil Evaluator l►I° . TY Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS NF-iOLACE . S7J/VLY L BOK N01 ZLW�X -
The and 'grid agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthe� /too ce �th�eJ�ysnte% in operation until a Certificated Com a has been issued by the Board of Health.
Signed =�4� C1iV `(�Cl� Date
Inspections
No.
COMMONWEALTH OF MASSACHSETY
Board of Health, - 11-7 j?OU
l 1L %{ r
CERTIFICATE O COMPIIANCE 14
Description of Work: C individual Component(s) -' ❑ Complete System
The undersigned hereby- cceer'ttiify t -h, alp j eSewag Disposal System; Constructed ( ), Repaired ( ), Upgraded (P)/Abandoned ( )
at cX 4- 51T t,
has been installed in accordance with the ro 's' ns of -3 0 CMR 15.00 (Title 5) and th pproved design plans/as-built plans relating to
application No. 7" r�' ,�dated " A '� /. Approved Design Flow 2_46 -pd)
Installer
Designer: 0f t.0 0 7 MC IN CCO J J (� Inspector: &_ EtN, lDate: 'd
The issuance of this permit shall not be construed as a guarantee that the system will f.2fi n as designed.
No. ( a ' FEE J
ZY
COMMONWLALT14 OF MASSACHUSETTS Lj
Board of Health, \/f�
'y%(��4 MA. �/
DISPOSAL SYSTEM CONSTRUCTION PERMIT 1 /�Oj� k�l �t7
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade ( Abandon ( ) an individual sewage disposal system
at 113 .f q � -7 as described in the application for
Disposal System Construction Permit No., dated/
M" / i
Provided: Construction shall be completed within three -Ss of the date of this per I it. All local conditions must be met_.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dates ~L/ 7 Board of Health