HomeMy WebLinkAboutApp-Permit-ComplianceL" FEE
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e� : TIS HEALTH ® PT. `
Board of Health, 1144-3, R(31-DTF 28 MA. A4 M? C':feiolew, 13,1, X•t�l�
&a14-5; APPLIC �[[J�TION PERMIT
'OfApplicatiorf for a Perm>t to Constru t() Repair( ) Upgrade$b Abandon() - ❑ Complete System ?Individual Components
Location C1 Li ` L K )Gw kll N AI'L,
Map/Parcel# �73 &e7• .24 Y'G
Lot#
Installer's Name
Address Q AIWN�"),-``", .2
Telephone# F�- Teleph°ne#_�S
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) gpt
Plan: Date Number
Title
Owner's Name
5 ,d I Address Cfq
Telephone#
pr's Name
Size
sq. ft.
Garbage grinder ( )
_ Showers ( ), Cafeteria ( )
>w provided gPd
Description of Soil(s)
Soil Evaluator Form No. Na ( iluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees pace the sys Aeration until a Certificate of Co plianc has been issued by the Board of Health.
_.k Signed �/ Date C�
t Inspections Sods ok- JOo/7/U1F
No. < �? Z • r d' IC r f'/G: l �/JEEE l - lJ f✓
Gr
COMMONWEALTH OF MASSAC14USETTS A"I if� r� �f37,
Board of Health, , MA.7
C EPITIFIA�omplete
OF COMPLIANCE
P
Descri tion of Work: LJ Individual Component(s) l System
The and igned hereby certify that the Sewage Dis "osal System; Constructed ( ); Repaired ( Upgraded ( ), Abandoned
by: 69
-
at .Lh nCit1,(i3%�. GIiC�
has been installed in actor ante �hith the provisions of 3�1,0 CMR 15.00 (Title 5) and the'ap roved design plans/as-built plans relating to
application No- Id dated _Z J�'d. Approved Design fF�ow &1,4
d)
Installer S l cy !C."u At
Designer: l`�Ltia�l�l. (.t�►��Dt �_ Inspector: Date:+
The issuance of this permit shall not:be. construed as a guarantee that the system will'function as designed.
No. e� —297 � � S FEE 5�; 1!0
.Vbl r"
lXr�/• /4k'k � 4 Aclew Board of Health,
Permission she eb � r/anted to; Construct Repair( Upgrade( Abandon an individual sewage disposal s
Yg ( ( pg ) p ( ) { ) stem g p Y
at l c as described in the application for
Disposal System Construction Permit No el� /, dated
Provided: Construction shall be completed within thl4iof the date of thMerill local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1 v U Board of HealthC.�?