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HomeMy WebLinkAboutApp-Permit-Compliance1143 Y4k1%UprZ2113 FEE r 'l.®MMO Wir.ALT14 Of MASSACHUSETTS Board of Health, , MA. v APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ❑ Complete System ❑ Individual Components Location &1 Owner's Name f-p,Qefr n e IT" Map/Parcel# / ?� Address Lot# • 3`7 Telephone# Installer's Name S 13r611A4rS M'n � CC Designer's Name D� ' 13, A' Is " n Address j~jg `r 4 -of Address ys� S9.76/�1 Y -/h Telephone# Telephone# e3 - iF l I t Type of Building 1�J Lot Size sq. ft. Dwelling - No. of Bedrooms 3 Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures 00 Design Flow (min. required) G O' gpd Calculated design flow t G� Design flow provided :W gpd Plan: Date l G% / t Number of sheets ' Revision Date Title Description ofSoil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS S -e- ? j9 ,j The undersigned afire p to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees,to d e th in on until a Certificate of om lian bee; b the Board of Health. Si ned ` Date —+ Y Inspections FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, VeorW-/Y!!/L%71 , MA. CERTIFICATE �Of COMPLIANCE Description of Work: ❑ Individual Component(s) ❑Aomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,( -6 Abandoned ( ) by: LZ &I S &g-,05 - at r s f1F12 ,�2i�S� has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 9 -22* , dated Approved Design Flow 5*(gpd) Installer &z [. f S 6Foo S Designer: Afyej/ > Inspector: Date: _ The issuance of this permit shall not be construed as a guarantee tha the system will function as designed. No. COMMONWEALTH Of MASSACHUSETTS Board of Health,yd'IZvxI�U/�' MA. DISPOSAL SYSTEM CONSTRUdON PERMIT FEE Permission. is hereby granted to; Construct( ) Repair( ) Upgradp�b) Abandon ( ) an individual sewage disposal system at 1,LtjV 5c as described.,it application for Disposal System Construction Permit No. 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 (i! `1-V / ( Board of Health i