Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. o v- D C'4L-4e5fo I>LD-r--.-I-7.0 D 30Z2 - FEE h�s`l(sBoard of Health,��t� MA. PLICATION FOR DISPOSAL SYSUM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(IYj�Upgrade( ) Abandon( ) - mplete System ❑ Individual Components Location/— Owner's Name iIc /yam/% Map/Parcel# / 3 Address p„Z/7- Lot# Telephone#3✓-- Installer's Name Po a0� .�'C�751C .,i�et G Designer's Name dE7 .i�ts�r7l� Address 3 j'o _��ci iy 5.77 Address Telephone# ,$©d'= 77.f ,2�a j— Telephone# f— Type of Building Lot its Lot Size QaPy�— sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) �3 �d gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets j Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS „ ��// ����� /,g Cb / �gce&�Z G To,�w 4. /otsr> 4SV arc � -- &�-i ,rf li .pvt �t /ars. ���srr -le 1-7iF3 _cis! _740,J-0 x 7/ 7y x z � The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Board of.Health,�.�®Q,, CERTIFfCATE, Of COMPLIANCE Description of Work: ❑ Individual Component(s) 'Complete System The undersi'ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ),Abandoned ( ) by: at has been installed i acc ce with the ovisions of 3,10 CMR 15.00 (Title 5) and the p oved design plans/as-built plans relating to application No. date Approved Design Flow (gpd) Installer Designer: Inspector: Date: T The issuance of this permit shall not be construed as, a guar'` tee that the sysY m will function as designed. No. (o—l� 0"voGe CQc) S�C JVc 3 FEE I� Board of Health,, ' �y �arrau�` L! MA. .,DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(-, ' Upgrade( ) Abandon'( ,) an individual sewage disposal system at d o►s' S - / ` as described in the application for Disposal System Construction Permit Nol � �' 7dated r r Provided: Construction shall be completed within thTe&Tcan of the date of this permit. All local ozr itions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Datel- % oard of Health P✓G �' l�jr"r 'S�`—�-_f.: < �.rl.✓ F��..LY//`7 G.�. X77 fc� " ("�,ys+,✓I, �f' J`egjq