HomeMy WebLinkAboutApp-Permit-ComplianceNo. �((/ t /�yU ✓ —" / 2— FEE 6 01
ETTS-
Board of Health, /i'Q���R?o" l fc r? MAS
C Aa�� '., if --Rad 'iMTKNON
APPLICATION FOP, DISPOSAL
Application for a Permit to Construct( ) Repair (W/Upgrade(W-Abandon() - ❑ Complete System'CJ Individual Components
Location CIC
Owner's Name
Ejr,,e;M r A)u £
Map/Parcel# 114 1 Z
Address
Lot# Z
Telephone#
Installer's Name �`/I 1 CO
Designer's Name 'Vico SEp774/L
Address 61-3 A'a
Address zd
Cp/YJ�AsS , �)g /S 021.38
Telephone#
Telephone#
a V Z4
Type of Building � 2r-46 &r,= Lot Size i 31s�8 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re
Plan: Date
Pie
Description of Soil(s)
quired) 0 gpd Calculated design flow 1?1A a i to
9 / /-S'/Q S Number of sheets ON,E--
s
Soil Evaluator Form No. 3 6l0 7 Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS RE P4,4CE- S #I S
Design flow provided Z98, 6 gpd
Revision Date
Date of Evaluation 9
The undersigned agree to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton p e the system 'up o eration until a Certificate of Compliance has been/issued by the Board of Health.
Signed Date
I`
No. ®`v _. / H i "W% FEE S _.
Board of Health, G el" L 'AM.
CERTI IC4E OF COMPLIANCE 7) -/j
Description of Work: 011ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: I `� c
at �i_i. (�( :�1 rP (�. r C �c' h Cj
DKA
has been installed in accordance with the provisions of 310 CMR 15.06'(Tide 5) and the proved design plans/as-built plans relating to
application No. t1 dated �Z Approved Design Flow (gpd
Installer J C c �Gy ,,�
Designer: f `/ L'� ( C Inspector: 2u 6i Date:
The issuance of this- permit shall not be construed, as,a guar4ntee th _t the system. will function as designed.
No. tl1 - g`! _ FEE
COMMONWEALTH OF MASSACHUSETTS
t; l Board of Health, -` MA.
%-
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at is d {^ J -e OZ_ c C a , ; y (-JS c ` t ! %'� r / - as described in the application for
Disposal System Construction Permit No. L16—# �1'// dated
Provided: Construction shall be completed within t q sof the date of thi/p .t All local c/ond' 'o
Date ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA -0 6 Board of Health �nn