HomeMy WebLinkAboutApp-Permit-ComplianceNo. ® 1 )�/
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Boa 1�JTE 28 MA
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APPLICATION FOP DISPOSAL SYSTLM CONSTRUCTION PERMIT
.Application for a Permit to Construct( ) Repair (✓UUpgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
s- 1V0yW' aeP a6p
Owner's Name @ y
Map/Parcel#
9 e) r
Address
Ilt#
Telephone#
Installer's Name
n e
Designer's Name
Address
Address
Telephone#
•y ,o f —7 7 S` 3
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided 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
a
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 agre t to place the system in ratiortificate of Co pliance has been issued by the Board of Health. 010,
Signed `// 'Date l 0 03
Inspections
•`%
No. % FEE 9" c
COMMONWEALTH Of MASSACHUSETTS.
Board of Health, V (.12 Y' vtn t- MA.
CEPITIFI -OF COMPLIANCE / it
Description of Work: ❑ Individual Component(s) ❑ Complete System `
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: - /9
at ✓ i4 Y w a o _....._....._...:. ...
has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. - -)-77 , dated ' Approved Design Flow (gpd)
Installer 115C R -C
Designer: Inspector: U°'` Date: IP)
The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed._
No.�! t FEE.
Board of Health, _ y' ` MA.
DISPOSAL SYSIN CONSTRUCTION PERMIT
0 hY
Permission is hereby granted to; Construct( ) Repair( Upgrade ( ) Abandon( ) an individual sewage disposal system
at S /�A i' G(iyy �� as described in he application for
Disposal System Construction Permit No. 0 77 , dated
Provided: Construction shall be completed within three years of the date this permit. All. loca onditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ( Board of Health .