HomeMy WebLinkAboutApp-Permit-ComplianceNo. D�. � FEE /�[ C(
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repaid) Upgrade( ) Abandon( - ❑ Complete System WIndividual Components
Location 2 7 COGV 5 1 5 /fwe-t
Owner's Name 57- v : � o�inon h/
Map/Parcel# Z
Address 2 7 L -Q CUSY 5T
Lot#
Telephone#
Installer's Name At -,6 61,4co
Designer's Name
Address �Q S %
Address
Telephone# j 8 7% 5-- Z E?00
Telephone#
Type of Building P' olds; Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date 3-tg-oq Number of sheets
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS I n5TA-t \ -% 13 O K
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the -provisions of TITLE 5 and
further agr n
o not to place the system in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed IDate C%
Inspections
q
No.
4 r COMMONWEALTH OF MASSACHUSETTS
Board of Health, 114�' 1�{�y I"`= MA.
FEE
D 60,�
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired), Upgraded ( ), Abandoned ( )
by: �41t A 'E)C.'.CA f) C O
at _Z -77_U_(7 tJ J
has been installed}' cora with the provisions f 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. '✓ `/ /, date ��t9 d r�-Appro d Design Flow (gpd)
Installert-- -t'6 CQWC O' d
Designer: Inspector: Date: 3 _ (Q
The issuance of this permit shall not be construed as a guarantee that the system will f ction as designed.
No. ® f �3 FEE �L
COMMONWEALTH OF MASS AC14USETTS
Board of Health, y/9_1010ok1k, MA. �cJ�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon ( Van individual sewage disposal system
at o? 60C u s T sr C�as described in the application for
Disposal System Construction Permit No. ! dated �;_(? U
&GvwS
Provided: Construction shall be completed within threrTen s of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date .i 6 /Board of Health a C/�