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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ~rl t ' • FEE6, Lam % Cg, ® ®�� I hAn ® H ATH DEPT MASSACHUSETTS Y _ 71271F-- Ofo 0—^ c ROUTE 28 APPLICAT=ION :F0:R �1 4MMNMA. CTIO ER I 1 Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components Location L;/�/�f'©tet/ ,I�Q� Owner's Name 6 e Sdj (/ Map/Parcel# Address 4� 411/ 4101--, Lot# Telephone# Installer's NameA /��P✓ Designer's Name�� L� G Address r / (�a2 &,,,n,, Address ,2 iy opJ �i �/ /I�/ ��ij •rc Telephone# S'a8- 4 Q !G O -- r? 70 1Telephone# if p j- 6 j e 0 Type of Building Dwelling - No. of Bedrooms Other - Type of Building — No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided 34ff, j 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 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees of t th tin operation until a Certificate ofnCphance has been issued by the Board of Health. Signed Date �- Inspections No. FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, q4a2snw�4^;11 MA. CEPITI ic�T E Of COMPLIANCE Description of Work: ❑ Individual Component(s) CQ omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed O Repaired ( ), Upgraded �<Abandoned ( ) by: zi at a "Al has been installed in accord e with the rovisi s of 310 CMR 15.00 (Title 5) and proved design plans/as-built plans relating to application No. �P2 -/9', �da�t�egd.���/ Approved Design Flow 3�(gpd) Installer �f'Pp�1 (/r✓✓rG-ti f... Designer: L `�- Inspector: u Date:'M� �... The issuance of this permit shall not be construed as a guar tee that le system will function as designed. FEE O . !/L./ COMMONWEALT14 Of MASSACHUSETTS 92-4 Board of Health, l MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; CC nstru ( ) Repair ( ) Upgrade;(/ Abandon ( ) an individual sewage disposal system at 1� �//_- e^- ,} as described in the application for Disposal System Construction Permit No. �, dated5� U G.�. ) Provided: Construction shall be completed within three-yefi gthe date ,of this periTO. All. local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date '4y -Board of Health