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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE COMMONWEA I# btpj�-/ AkQ RQ UTE 28 Board of Health, SO. YARMOI 1TE.r MA 2&4 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair CXUpgrade() Abandon() - ❑ Complete System ❑ Individual Components 'ivy Location . ST Owner's Name /0OP- Q i 5 " }t e Map/Parcel# h Address O&) aue $T Lot# Telephone# i Installer's Name VL) Designer's Name O 1 S&rzv- Address n,f T C? . 11c Vl l.V l Address '1166-14 (/JTV U G, --� Telephone# L— S Telephone# �3 Type of Building Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required) l Plan: Date Title Description of SQil(S) _ Soil Evaluator Form No. No. of persons Lot Size sq. ft. Garbage grinder PJO Showers ( ), Cafeteria ( ) gpd Calculated design flow -3 ---in Design flow provided _,� gpd Number of sheets Revision Date DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator S I/ .4 --r Date of Evaluation f / - % `/' Q The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further aj ees�too not t�ace system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed L' V_T� !! Date -2� Inspections No. U � 3 7 AAJ T�rairc°� r�io� FEE `�'✓ Board of Health, az MA. i CERTIFICATE Of COMP]LIANC E,�,V . Description of Work: ❑ Individual s Com onent ' p p () ,�CompleteSystem � The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( by: at _ ZV gr has been installed in accordance with the provisions of 310 R 15.00 (Title 5) andtheapproved design plans/as-built plans relating to ,' application No. 4 2 -3-7 dated / , j- © 4 Approved Design Flow 3.3 3 (gpd) Installer Ae ! rI Designer: 1-15i"�i1 G Inspector: Date: - The issuance of this permit shall not be construed as a guar tee that A system will function as designed. No. Cid H 4 . COMMONWEALTH OF MASSAC14USETTS k , Board of Health,MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT . - FEE �- la ,,I Permission is hereby granted to; Construct( ) Repair(,< Upgrade( ) Abandon( ) an individual sewage disposal system as described in tht- application for Disposal System Construction Permit No. G�� �"% %, dated ^d Provided: Construction shall be completed within th�P of the date of thispermit. All local conditions �u/st�be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date'/- C! �- Board of Health C� ��=J