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HomeMy WebLinkAboutApp-Permit-ComplianceNo. /7-- 2, COMMONWEALTH OF MASSACHUSETTS FEE5.31© v C GG D-7 - ?Bow of Health, l�'y �T MAT �T }�� APPLICATIO�T ±COR DISPOSAL S�T ST CONSTRUCTIO PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( L Complete System O Individual Components. Location�� tt/. f Owner's Name D ✓tL r Map/Parcel# b?, d t 2(�j Address Lot# Telephone# Installer's Name . f Designer's Name Address17 9 L k4 dA ,W�� Address X - 7&-g, LWOiJ Telephone# o D V `L Telephone# '') 7 r Type of Building _ 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) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets ' Revision Date Title Description of Soil (s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator of Evaluation �le _r 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 place a sy t operation until a Certificate of Compliance has been issued by the Board of Health. Signed /.at Date Id — 7_31 - Inspections • ' COMMONWEALTH OF MASSACHUSETTS Board CERTIFICATE HMA. u, Aealth, Citi 1�[� COMPLIANCE, Description of Work: ❑ Individual Component(s) &Complete System The undersigned hereby certify that the Sewa a Disposal Syste Constructed ( ), Repaired ( ), Upgraded { , Abandoned ( ) by: at - 4t(. has been installed inaccor4danc� with the revisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. :' ' i, dated i� ?Approved Design Flow. .(gpd) Installer L yjke lJ Designer: 4 ,; � t Inspector: Date: The issuance of this permit shall not be construed as a guarante at the system willfunction as designed. No. Elkv\ D Pt V t -t i �-- `� [)� � 1 � i : FEE /7- = 7 COMMONWEALTH OF MASSACHUSETTS .Board of Health, DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; i at e r Z e ,_,V 1 ) n Repair ( ) Upgrade�-<Abandon ( ) an individual sewage disposal system Disposal System Construction Permit No. j7 --,)_?'7, dated Provided: Construction shall be completed within th, yF rs Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date /di / Aoard as described in the application for of the date of this perji]t�,Ad, 1 local condi ftins must be met. of Health , / 0/ (Az