HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60 WDC— 17 —00
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Board of Health, 1146 ROUTE 28 MA.
APPLICATION FOP DISPOMY ?RMA CTI®N PERMIT
Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon() - ❑ Complete System f Individual Components
Location
53L cp , 7
<—, t -AxL c
Owner's Name Gi 4-Lcem LAPos.4
Map/Parcel#
90 13 9
Address 5a Cou cco TA-- S. -Y.
Lot#
Telephone#
Installer's NameL
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building C --s t'0 Go —r t Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Rcpt-I)—boy- ,4k& ly<T Atsa
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed t Date
Inspections
No. 10 4 D c — 1 7'00 U• ( ,
COMMONWEALTH
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'l_OMMOI�W1r.LTH OF MikSSACH SE P1 FEE oS3-7
Board of Health, MA.
CERTIFI AM U1 ®M l[.IANU
Description of Work: Mindividual Component(s) ❑ Complete System .�.K.,-.._
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (, Upgraded (\), Abandoned ( )
by:—�„��Cl l�l�J� ESV (�� ��� W<MAAD<!AP4E)J
has been installed in accorcla e with the rovis ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / rGr�� dated �� 7 . Ap oved Design Flow (gpd)
'Installer Lj (D( CSER A
Designer: Nb* Inspect r: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �� (� V " VO 8 FEE OtJ
7-- COMMONWEALTH OF MASSAC14USETTS
Board of Health, YAP -mo OT -1-4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade ( ) Abandon ( ) an individual sewage disposal system
ate�r. �Ot>1VZb"ty D�� 5. as described in the application for
Disposal System Construction Permit No., dated -7--S—/
Provided: Construction shall be completed with�� 'sof t;idate of this permi . All
�local condi 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / �+ �� /Board of Health