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HomeMy WebLinkAboutApp-Permit-ComplianceNo. f'()VW()XTA1rfATTH ®E AAAQQACH1jQETT1Q W ZBoard of Health, ��de�zsf5 MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT INicationlfor a Permit to Construct( ) Repai�L pgrade ( ) Abandon( - ❑ Complete System C�tfc{ividual Components L cation omay( e Owner's Nam4-1 Map/Parcel# % '/'/ ,77 -a6 Address- Y 3d 4,7- Lot# Telephone# e Installer's Name �� �, 1 Designer's Name Address Address Telephone# 'a �, _ y Telephone# Type of BuildingLot Size sq. ft. Dwelling - No. of Bedrooms �� Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided 57 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 rVolelo / 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 Lq place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed i Date Inspections No.—1?�"-�� COMMONWEALTH OF MASSACHUSETTS, Board of Health, CERTIFICATE OF COMPLIANCE /4,/ Description of Work: 9ndividual Component(s) : ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 41,Upgraded ( ); Abandoned ( ) by: at 14 CAPT. `,)i mr-o � has been installed in accordant with the provisions of 31 CMR 15.00 (Title 5) and hea proved design plans/as-built plans relating to application No. dated Approved Design Flow (gpd) (gpd) _,.-------- Installer �• . - _. . s; Designer: Inspector: L / Date: y The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. �owDc-k) C -APE COD Se7 +tC 3VCS- FEE 06 COMMONWEALTH OF MASSACHUSETTS Board of Health,. DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at .-� S, i� .< % as described in the application for Disposal System Construction Permit No. , dated Provided: Construction shall be completed within dwei-- e2rs-of the date of this permit. All local conditioris must be met. n / 1 Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date % % 7 Board of Health<