HomeMy WebLinkAboutApp-Permit-ComplianceFEE i
aq-
Wl- �alL @'r� ��T6� I
Board of Health, «. _ e •-�-�-- ,
RM
APPLICATION FOP, DISPOSX�- M- T ft%WJCTION PERMIT
+ Application for a Permit to Construct (/Repair Upgrade (,I -'Abandon O 2f/complete System -Individual Components
Location
Owner's Name
{)7 e°c //I
Map/Parcel# , lie �-- �,q� 02 d.
�n ddress k) 3
k4ft 11Y� Ad-
Lot# >-- 6.7 />e)
Telephone#
Installer's NamelY
Designer's Name
ce'r
Address2 17
7
Address
Telephone# k72Telephone#
:77'7 ti -
Type of Building /�°��%� 7/ 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) gpd Calculated) design flow .Z Design flow provided 33k gpd
Plan: Date So. I Number of sheets / Revision Date
Title
Description ofSoil(s) -PY So.' ( raj
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S�ef- ge ad V DYC I •(�ln/)
-V
The under igned agrees to ins the above escribed Individual Sewage Disposal S stem in accordance with the provisions of TITLE 5 and
further a es ton to la the o eration until a Certificat of Com ce has been issued by the Board of Health.
Signed Date �v
,0
Inspections
No. el 10 FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, ^+ I' MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded e<Abandoned ( )
by: ; ( eproywr5 Cies 0 1
at J n l -
has been installed in accornce with the provisions of 310 CMR 15.00 (T&V 5) and
application No. 0Z`. t , dated //-/57 Z 2- Approved Design Flow
Installer 17- It 1. bi'Oq7-Y1K Gari • 60
Designer:
The issuance of this
No. U .0 -1�-
Inspector:
(gpd)
design plans/as-built plans relating to
Date:
shall not be construed as a guarantee that the system will function as designed.
eZ L- ( S
Board of Health, MA.
DISPOSAL SYST CONSTRUCTION PERMIT
FEE (2c j((,,
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at E i) j l `� �',.t C < '� ( / U� �o %'� `' S� %"`� c "� /% ales ibed in the application for
Disposal System Construction Permit No. �, dated // -/S G' 2
Provided: Construction shall be completed within VV of the date of this permit. All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -?-Board Of Health
/ " C�-�C"X•f L-- -
i
t
A41
`� l l . � 30 —Te
T '' vo le4�
O
o �� r L
So 5�
Z �l
9
.fL
Ir c �
u
<,e u )A d Neq
l\ N Y