HomeMy WebLinkAboutApp-Permit-ComplianceNo. i * FEE 4570
Vie# 7v &zTCO 'l[MONWEALTII OF MASSAC14USETTS
Board of Health, MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairAj Upgrade( ) Abandon( ) -,*Complete System ❑ Individual Components
Location
Owner's Name
L l �(tQ-t f
Map/Parcel# 5
e- 2-
tj Address
a eu A -i -ems 44a -
Lot#
Telephone#
Installer's Name aL
t e ,
Designer's Name
Address ' 4 C !an Se h
A s. -t UJAQ
Address
� S44 /341 .,
Telephone#
Telephone#
Type of Building J(/1C t -e 4 l41n %a Lot Size
Dwelling - No. of Bedrooms 3
Other -Type of Building No. of persons
Other Fixtures
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) r3 3 d gpd Calculated design flow 337- ttDesign flow provided 33'7- 5%pd
Plan: Date 11-2-(1-5S Number of sheets t Revision Date 06j? =(?
Title
Description of Soil(s) 13e- 0 146
Soil Evaluator Form No. Name of Soil Evaluator DAU D W -Tc it Date of Evaluation 0-1-0-56
DESCRIPTION OF REPAIRS OR ALTERATIONS &.►T�XS, iie- E[ decl C SOmi S
The undersigned a ees to install the above described In 'vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to pla the tem in o ratio r t
fil a Certificate of Compliance has
been issued by the Board of Health.
Signed Date
aInspections
No. f /� �G FEE
COMMONWEALTH. OF MASSACHUSETTS/ IJ,
Board of Health, YkE'i oo ALJ , MA.
CEPITI ICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Arcom�lete System
The undersigned hereby certify tch�at tb, O
Sewage Disposal System; Constructed ( ), Repaired,, Upgraded ( ), Abandoned ( )
at Z l L {4 1,e Lai ✓! E'
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �l'/Q dated 7�; Approved Design F11133_7. (gpd)
Installers-
Designer: �> 6 C ley, U/ , Inspector:
The issuance of this permit shall not be construed as a guara
Date: V3 f7
41
that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, e'!& d u � h MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at 91 /
L! 111,0 /) 1I" e.,e
FEE-- jj 56
vw`
XUpgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. `/off, dated/
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -3 %Gard of Health