HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0--37 FEE
C®MMONWLA4 f .A"L�WTS 6,G`1- -!b�
_ Board of Health, 1146 ROUTE 28 , MA.
M UTH, MA 02T
APPLICATION FOP, DISPOSAL SYST��'1[ CONSTCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location :341 S+A-Vo n A-✓kl-
Owner's Name pffV n
Map/Parcel# 01j
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Address q 5+pdct1on `p-.
Lot# rj 3IT&O
vy
Telephone#
Installer's Name �f�
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Designer's Name OWY'\ C16%e 1 1
Address Zo /1//�urtion
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Address q3-1\ yl,y-i,h S rCY16
Telephone# �(�� —
�� -2�Vo
Telephone# (� C,._ y57
Type of Building ��e ` �1 ` d t "`/ Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures /'
Design Flow (min. required) 404) 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
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -LC tJ'tl�-1 U /`I - "�"�' "4
The undersigns agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o of to placeY7em ' oper tion until a Certificate of C mplice has been issued by the Board of Health.
Signed Date
Inspections
s
No.7� C®�9[�9 ONWEALTH ®L' MASSACHUSETTS FEE
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) U'Complete System
The undersi ned hereby certify that the Sewage !rDisposal System; Constructed ( ), Repaired ( Xupgr&d ( ), Abandoned ( )
by: iP
at AV 'E'
has been installed in accordance with the provisions of 31/0 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. D� _ i��r dated �! Approved Design Flow (gpd)
Installer C AA6 t A
/
Designer: R W h —iF e. Inspector: ` Date:
The issuance of this permit shall not be cons ued as a guar tee that the system will function as designed.
No.� C f� 3C FEE Ipj
COMMONWEALTH OF MASSACHUSETTS Y/ ;7,f
Board of Health, ✓WG'Z /, MA.
DISPOSAL SYSTL 'l[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (grade Abandon ( ) an individual; sewage disposal system
at Sq �kWtaCi'or fin, Vim-- as described in the application for
Disposal System Construction Permit No.�7=; dated
Provided: Construction shall be completed within thv � c i -the date of this per All loc 1 condi 'ons musx•b met.
—c Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �- L/`)Board of Health