HomeMy WebLinkAboutApp-Permit-ComplianceNo. IJd17Y�i�7/%'G�C " �/ FEE
VAOMMONWEALTH Or MASSAC14USETTS 2�
Board of Health, .1 a1�e gel -1 MA. ✓
t
APPLICATION r®R DISPOSAL. SYSTEM CONSTRUCTION PERMIT
OIplication for a Permit to Construct( ) Repair�pgrade ( ) Abandon( - C� Complete System ❑ Individual Components
ocation
Owner's Name _ Low
ap/Parcel#
Address
ot#
Telephone#
Installer's Name `r�!
Designer's Name �`f o'i iy
czz �� G
Address
Address
Telephone# S- ? _ Z
Telephone#
i
Type of Building .�/rt Si�� �jj Lot Size Z,:5; 2'.� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) ✓' gpd Calculated design flow
Plan: Date J/ <o l T Number of sheets
Title ,/� ap-
Description of Soil (s) —
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided 33 3 gpd
Revision Date
Date of Evaluation
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 ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed � ��" �`� 1 , Date �gzzzr
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No. d Tn 1 7 G� E' CSC)
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Z!!�/ MA. D
CERTLfLCATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) OIC/omplete System
The undersigned hereby certify that the Se ge Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
by: �'�a - . i � !'cam r r� ("� / r- /'� e t;"
at- rr c, / /� ,a S- ?-1-
has been installed in accordawith the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 1 dated C-.>-7 _ oApproved Design Flow 7r(gpd)
Installer - — - �-
Designer: Inspector: Date:
~ The issuance of this permit shall not be construed as a gu tee that the system will function as designed,
No. QNDC'oI r "'`f 1C] cAv�, r0D sent secs, FEE �O�
COMMONWEA LTH Of MASSAC14USETTS
Board of Health, �YG�e>�/� MA.
e
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade ( ) Abandon ( ) an individual sewage disposal system
at? f;i v c..TG- 1 fG�- _S�e- as described in the application for
Disposal System Construction Permit No. dated -0/'f) !
Provided: Construction shall be completed within -t reee years date of this pe All local condi 'ons must be met.
Form 1255 Rev. 5/ 6 A.M. Sulkin Co. Boston, MA Date 60 -,)�,/Aoard of Health