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HomeMy WebLinkAboutApp-Permit-Compliance.S � YA,'al7dda%JIla+ I N V'2a-AL I F1 IJQF- a e No. / /`t0 j 1146 A'OU E 28 227WI�;— -732!Z FEE SCS. W RMOU H, MA 02eS4 V l//i5lCb -0\ Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade44/Abandon() omplete Syitem ❑ Individual Components Location p I -AZ Owner's Name Map/Parcel# I �t -� ,4.L f ,1 -- Address Lot# /^1 vl is �� Telephone# Installer's Name �j�� fr ( e Designer's Name Lf, Address Ct 16t�G 14, V& CC Address Po (jg iC ? B q Telephone# ? IF © -- 5`,5^ k- Telephone# Type of Building Lot Size F40 0, sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Z- Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) Z3 gpd Calculated design flow Design flow provided— gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation O " l -?-9? The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to p ace the tem in operation until a Certificate of Compliance has been issued by the Board of Health. ° Signed Date Inspections No. - FEE C®MMONWEALT14®F MASSAC14USETTS � � Board of Health, -J?, MA. (, CERTIFICATE &COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersignedherebycertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (17,*Abandoned ( ) by: L r vI has been installed in at application No. Installer with the provisions of 310 CMR 15.00 (Title 5) an th app oved design plans/as-built plans relating to dated 121-Z-- T,5. Approved Design Flow gpd) Designer: Z- l Inspector:ZL-j- YVI Date: 1 a` V (DC) The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 77 6-�?/. j� CFEE COMMONWEALTH OF MASSACHUSETTS Board of Health, oell , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT 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. �Z-J�;vw > dated -%y Provided: Construction shall be completed within three years of the date of this permit. All local conditions must � et. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� Board of Health /(�2e�