HomeMy WebLinkAboutApp-Permit-Compliancef _
No. FEE
v .
1146 ROUTE 28
c` Board of Heal &^. MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade/Abandon() - Complete System ❑ Individual Components
Location
/1-1 �,� L�
Owner's Name
I—
Map/Parcel#
5 --3
Address
Lot#
S
Telephone#
Installer's Name ty� N y �p
Designer's Name
Address
Address
Telephone#
7 `7 7 s7 3 Ca
Telephone#
5--0 a
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size
sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) J �� gpd Calculated design flow — Design flow provided T gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS /^7 r+�
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 agree not to place a in ope!!Oper opera'a Certificatef oCom fiance as been issued by the Board of Health.
a , Sign` �. 'Date 7 3
s Inspections
f
No. —s COMMONWEALT14 Of MASSAC14USETTS FEE �0.
Board of Health, � , MA.
CU
C ERTIFICA1 ®F COMP' LiANCE
Description of Work: ❑ Individual Component(s) ®''Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Arbandoned ( )
by: ") i;2.- �' 147"
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. V'7! - dated "" Approved Design Flow (gpd)
Installers
% jam'"< A,�j!`, r'
Designer: /-ri / 1��r,,7/ tt� Inspector: I Date: /l% e
The issuance of this permit shall not be construed as wguarantee that 4e system will function as designed.
No. -/ -G. f Y't .. % FEES
COMMONWEALTH OF MASSACHUSETTS
Y
Board of Health, Z � , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(,'Repair( ) Upgrade(, Abandon( ) an individual sewage disposal system
at G``/ as described in the application for
Disposal System Construction Permit No. --) / CZ)
) dated �� C ' /, -3
r ,
Provided: Construction shall be completed within4kf - � o the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date i% )Board of Health / `�