Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE J d COMMONWEALTH OF MASSACHUSETTS Board of Health, � , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 2-y W I -11blepsle Owner's Name s2Q `j e j�5' Map/Parcel# 16-7 6W I I9 Address .. Lot# Telephone# Installer's Name I�avS/%1l / � ,le Designer's Name p-6 e- z/V (l� Address 15o." e -TX1V Je Ag,:5.7,-�� Address ZF ...5A'/1a Telephone# (ffes2016 Telephone# JrJ2 9-1-7 Type of Building '°s% ai Al -J�li �4i Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) -?3© gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Gig *O- &4 4Jtai1 Date of Evaluation r'%41 % DESCRIPTIONOF REPAIRS OR 4TERATIONS l �d fi`Ea'77 The undersigned agrees to install t1W above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree of t:}n operation until a Certificate of Compliance has been issued by the Board of Health. e Signed Date (//" Inspections No. — Description of Work: O Ixid'vi The undersigned hereby certify by: / - at at a y 141le-1) has been installed in accorda is application No. Installerrr P, e COMMONWEALTH OF MASSACHUSETTS Board of Health, ,/%lZ/Yl�au '�i "AIA. CERTIFICATE Of COMPLIANCE Cbmlionex�is) the Sewage Disposal System; Constructed ( ) , Repaired 4 TJpgrad FEE JD ), Abarr_donerl () with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated . Approved Design Flow •3S 7, A(gpd) Designer: il? �/(/f; n&pectpr /j. �� Date The issuance of this' nut shall not he coristrueil as`a' ar�ntee'tha the stem wi rriincd as�tlesi eco„ .. No. J % FEE COMMONWEALTH 7 _ Board of Health, `%ldt r lj MA. C DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair Upgrade ( ) Abandon ( ) an individual sewage disposal system at t/ / (-/j AC)5-e %��'i''.� ` - as described in the application for Disposal System Construction Permit No. �7 �, dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date '6IJ l c1$oard of Health �,�/% 77) -I %