HomeMy WebLinkAboutApp-Permit-ComplianceNo. �`� � /� FEES
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Board of Health, 1} iz,0 NO VIA
APPLICATION FOP, DISPOSAL ��M* ITION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
G t pi^
Owner's Name
pl <
Map/Parcel# p�
3 s
AddressZ�x
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Lot#
Telephone#
Installer's Name zlle
�y f j
Designer's Name
r
Address 1.5c
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f G(LtdG
Address ZIMIX
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Telephone# Yoe
b 09/ 'Z,
Telephone#
t7 %" Vr•z
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
rs
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow3 3y Design flow provided 3 17U gpd
Plan: Date Lf - V ; Number of sheets f Revision Date
Title
Description of Soil(s) ,� �/ i1J F �f
Soil Evaluator Form No. Name of Soil Evaluator 5,1,-g= Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS %h Qi // 6 e w JXJ-
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 p ce the syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections At -7-6;- 9-4:) /�,L
a
No. _ 7D �it{e C lo` .1 /:tl' '1AL114 Of MASSACHUSETT 477 FEE ,
Board of Health, MA.
CERTIFICA OF, COMPLIANCE 1),
Description of Work: U/Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal Sy em; Constructed (Repaired ( ), Upgraded ( ), Abandoned ( )
by: J -e f �j f es—
at Z 'i , C ,/yu 4/4 y 111 4
has been installed in acc da�j��j with the provisions of 310 CMR 15.00 (Title 5) and th a proved design plans/as-built plans relating to
application No. 9 r / L! dated AQ �� Approved Design Flow t� (gpd)
Installer C
Designer:�(" Inspector: ; <"'t" Date: i l
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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COMMONWEALTH Of MASSAC14USETTS
Board of Health, l MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade 91 Abandon( ) an individual sewage disposal system
at l/ Ei,/,
as described in the application for
Disposal System Construction Permit No. 7a , dated ID - S�
Provided: Construction shall be completed within ars of the date of this Vjm . All local conditions must be met.
Form 1255 Rev. 5/9``6 A.M. Sulkin Co. Bosto , _A Date/() �-� O� B/oar�d} of Health,
A7//i%l/1/; /A 4