HomeMy WebLinkAboutApp-Permit-ComplianceNo. L9 ✓
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C� Board of Health, 1146 ROU ;E 28 MA.
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APPLICATION FOP, DISPOSAT TION PERMI1
FEE60
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - Complete System ❑ Individual Components
Location
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Owner's NameVY 14,-4
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Map/Parcel#
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Address 'f/& C,./le it ee t
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Lot#
Telephone#
Installer's Natne
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Designer's Name
Address 7
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Addressa� '�
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Telephone#
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Telephone# 72
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Type of Building a Lot Size sq. ft.
Dwelling - No. of Bedrooms LJ Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date & L{��W3 Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS e `P
Date of Evaluation
The unde i anot
to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee tpl ce th a in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ! Date �� % \Q, -
Inspections
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No. GFEE
COMMONWEALTH OF MASSACHUSETTS �G� (�� 3
Board of Health, r. Mc MA.
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by; 1- 1 I- S &;-c l J-( j P S • cc, .
at S"iUO hj •� " I li z�
has been installed in accordywith the provisiQjs of N0 CMR 15.00 (Title 5) and th a roved design plans/as-built plans relating to
application No. 0dated G 1 d Approved Design Flow (gpd)
Installer i^ r J 1 v C CC C . it i
Designer: l (fir[6�ector: v& s/ V_Date: ?I/0�0
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The issuance of this permit shall not be construed as a guarantee that the system function as designed. ��
No. �% - FEE
COMMONWEALTH OF MASSACHUSETTS 3
ll �� b Board of Health, .ti. -T , MA.
U N� DISPOSAL SYST CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at J 1V G Q ) n P btl as described in. the application for
Disposal System Construction Permit NO. -�3 dated.
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Provided: Construction shall be completed within-+hTee- y�a� s of the date of this per i All local conditions must be met..
35 1
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 0 c)Board of Health
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