HomeMy WebLinkAboutApp-Permit-ComplianceNo. hw FEE �' 00COMMONWEALTH Of MASSACHUSETTSell,
_ • . Board of Health, '; 1 {"sl 77 ; 1VI4.
APPLICATION FOP, DISPOSAI!9'��' T6**�TION PERMIT
Application for a Permit to Construct( ) Repair(�rade ( ) Abandon( - ❑ Complete System ❑ Individual Components
Location t -7 AL., F[ w f L
Owner's Name - dn-spri
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address�N
Address ct
Telephone# —j-/00
Telephone#
Type of Building 1'lfhis`E
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size OAQ8 r 51k sq. ft.
Garbage grinder (, )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 33n gpd Calculated design flow 31/7 Design flow provided gpd
Plan: Date SeIjA IkPL Number of sheets Revision Date
Title
Description of Soil(s) See I&VO
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 15A -e i- c- sV 6tc- ,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to not to place the in operation until a Certificate of Comp fiance has been issued by the Board of Health.
Signed Date .�
e
Inspections
/Vre+
No. /2--�
'L-,OMMONWEALT14 Of MASSACHUSETTS FEE V L/
33�I
Board of Health, VQ f M -0 y A- �. MA.
CERTIFICATE OF COMPLIANCE ?j--j-eT .
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that t�v-
he�Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( )
by: �J� s / S a rr✓
at / -7 444 Y I—e- — -5—
has been installed in aaccor nce with the provis�ns of 31,0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �l ' Z�dated %n .�G ^ [J �j Approved Design Flow (gpd)
Installer,/ f1fOcyr� t► 1,
Designer: �]!!M SNC �D/� Inspector: (, / -)r-1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (/ — 72-- FEE
COMMONLLT14 OF MASSACHUSETTS
Board of Health, 74'-mcu�`k �,MA.
DISPOSAL SYSTEM CO CONSTRUCTION
PERMIT
Permission is hereby granted to; Construct( ) Repair�<pgrade ( ) Abandon ( ) an individual sewage disposal system
at /7 A& FX Wel /--oma
as described in the application for
�� �
Disposal System Construction Permit No. �7 atedc 140 � U.j
Provided: Construction shall be completed within of the date of this rmit. All local conditian s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /0 2 -`'0 Board of Health