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HomeMy WebLinkAboutApp-Permit-ComplianceZ No. >00C^ 1-745 `.'V z/wriv s MVV COMMONWEALTH OF MASSACHUSETTS Board of Health, �r MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(<Upgrade( ) Abandon() - W-C-1--'plete System ❑ Individual Components Location f" ��� �p Owner's Name 77.x., Map/Parcel# S Address/ -7 � X04 -0e O?l Lot# Telephone# Installer's Name ` Designer's Name ,voe,-,s Cc,+,01:! AddressAddress 3-� o Q s s 4i• ��•� � 939 p d8. r� Telephone#�6(14 Telephone#f off_ 3-2_ �9 Type of Building Lot Size /4; 3Z© sq. ft. Dwelling - No. of Bedrooms Garbage grinder Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min./required) 3r3 ® gpd Calculated design flow Plan: Date G'/✓`-//� Number of sheets Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Design flow provided .33 6 gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS t5lld�`e. �ze r ,ez ,2-s oma+ err-/ � szeo*,,9 2 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to/no� place the system o eration until a Certificate of Clian has been issued by the Board of Health. Date Signed ,/'C C✓� No. C "" 1 � "t,.r Jd � FEE l7= Board of Health,TT MA. CERTIFICATE Or (®MPAIANCE Description of Work: ❑ Individual Component(s) complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (�pgraded ( ), Abandoned ( ) by: at Z3 - has has been installed in accord e with the p ovisio s of 310 CMR 15.00 (Title 5) a th approved design plans/as-built plans relating to application No.= dated ��7 Approved Design Flow ( pd) Installer / ��--''_ f��`�'�<-'.---��-'Z_-. � s r CA�•1 - ��. Designer: DLw iJ (P P -- Es 1 lei Inspector: �� : j Date: �% ' f The issuance of this permit shall not be construed as a guarantee,Z at the system will function as designed. No. J� C I -7 -LIS -VS, Cf ; P(-- Cov Cm C. S V1�•� FEE `GQ� Board of Health, MA. DISPOSAL SYSTEM STEM CONSTRUCTIO PERMIT Permission is hereby granted to; Construct( ) Repair (Upgrade ( ) Abandon( ) an individual sewage disposal system j as described in the application for Disposal System Construction Permit No. f`�/t5 dated F% 3""/ 7 Provided: Construction shall be completed withiw4tr She date of this p rrm.t. All local copditi s must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health t-✓ ,�.