HomeMy WebLinkAboutApp-Permit-ComplianceNo. D �/ FEE
COMMONWk#9-09 MAPAMMETTS �V�4
1146 ROUTE 28
Board of Hea$0 YAflMOIJTH, AA A2& , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - .' Complete System ❑ Individual Components
Location o k 1,25 ��''` ':—�1m h
,�„s� Owner's Name
Map/Parcel#�� /7jj
Address
Cl ! k
l- v J
jyayJk
Lot#
Telephone#
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Installer's Name
Designer's Name
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Address 1? 0 ,[ )Or13
Address
f _ - J '60, °' ✓� 1 ' `� va
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Telephone# 60S _.--7-2 S-- 3S
Telephone#
JUct
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Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Ir
No. of persons
Design Flow (min. required) Ito gpd Calculated design flow .17i31AD
Plan: Date
U, A02. Number of sheets oru
i
Title
0
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
'''
Lot Size 4�, ✓ ) 0 sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided 2V�-'2 gpd
Revision Date
Date of Evaluation
'DESCRIPTION OF REPAIRS OR ALTERATIONS 1 6QX-) 6m, GA,., fa,.1li- Za, %" ala 'AntHs
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. t� � FEE � r
COMMONWEALT14®L' MASSACHUSETTS
Board of Health, �, , ,,,L MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) N Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Xl, Upgraded ( ), Abandoned ( )
4-9
by: �Cy)f C—J)'15�11rJov 0Lv-� . e
at UA, '-'Ir1f AawiL
has been installed in a „cordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ^% dated /2 -41 -4 . Approved Design Flow (gpd)
Installer �1 1
Designer: Inspector: �'JV! / Date:
The issuance of this permit shall not be construed as a guarantee that the system will fudction as designed.
No.
C®MMONWEALTII LF MASSAC14USETTS
Board of Health, 1:=r Q - VU , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 7 v
Permission is hereby granted to; Construct( ) (( R``epa�ii-N) Upgrade( ) Abandon( ) an individual sewage disposal system
at 4 cl Ohor \, ?� W 25! tlwli rno�. YL as described in the application for
sposal System Construction Permit No. a:4-'-�, dated - %
d: Construction shall be completed within tars of the date of this P4 r it. ;All local condition must be met.
Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ``,() -14 Board of Health