Loading...
HomeMy WebLinkAboutApp-Permit-Compliancek4d FEE t o C®MMONWEALTRA MASSACHUSETTS CtL'tl4 M Board of Health, ` . Py u ,4r1YLL1 �APPLICATION FOP, DISPOSAL'SN�T'r�'m,COX�-,TRUe-TION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location /T 0'% ,o -P l/Le Owner's Name LG Map/Parcel# Address T �t,Lot# Telephone# Installer's Name)` l t � j�p, �f' CC�47 Designer's Name Zc_, Address J j�tq - / Address 1*0- c" 9 2e -71 S jJ Telephone# Telephone# 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) 3 -1Y0 gpd Calculated design flow � Design flow provided % gpd Plan: Date Number of sheets Revision Date Title Description of S011(S) S',e-p S� Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS S e -e �� 9 /) U,17 Date of Evaluation �4 The undersigned ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t o 9t place a ation until a Certificate o� Compliance has been issued by the Board of Health. Signed Date �n F No. 66 6� COMMONWEALTH Of MASSACHUSETTS Board of Health, G �o CERTI FIC COMPLIANCE FEE To ok Description of Work: ❑ Individual Component(s) ❑ Complete System ©/( The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned () e by: -5 r /21-f S CC 4�) S)-. (G at R V el- ,-t ✓�j �' %. i /i � C 1 has been installe ii/n��� acc9 a e with the ov1 10 s o_f 3 0 CMR 15.00 (Title 5) a�' d%t approved design plans/as-built plans relating to application No. 616 / �� , dated - _�1 Approved Dein Flo (gpd) Installer l l G� � A S -C,-? SJ" - rC �i�i� -- Designer: -e -e iP!' f -'/V. "&/ p'" inspector: / (/�f f Date: The issuance of this permit shall not be construed as a guarantee that the system will function as. designed. No. V Y/ �1 L i .� FEE COMMONWEALTH Of MASSACHUSETTS P1 a. Board of Health, G'l ° MA. DISPOSAL SYST CONSTRUCTION PERMIT Permission is he``r}eby,granted to; Construct ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at t Disposal System Construction Permit No. 06—If f 3, dated as described in the application for Provided: Construction shall be completed within three years of the date of this permit. All local conditicns.must be met. 6 Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health