HomeMy WebLinkAboutApp-Permit-ComplianceNo. ¢' FEE\J�/ V V
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5-kei-p Savvi- C®MMONWEA TH Of MASSACHUSETTS lj7e�,Fb
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V- �l Board of Health,
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PLICATION FOR PSE MIT
Application for a Permit to Construct( ) Repair( ) Upgrade 10 Abandon Complete System ❑ Individual Components
Location
Owner's Namej'r
Map/Parcel#
(00/42-4
Address F.,
Lot#
Telephone# 6Dg-, 7
Installer's Name
00 64�'
Designer's Name �C &(�6 vP
Address t
O 17 E,� I4CS
Address ��� U / t W
Telephone#
_.
Telephone# -- -7-7
Type of Building IJ'
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size /" / 9 5,;,) sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)_ gpd Calculated design flow Design flow provided _� gPd
Plan: Date aq07 Number of sheets 1 Revision Date
Title '
Description of Sbil(s)
(IU / j/ ! 1 V J/T" j-) -7
Soil Evaluator Form No.
Name of Soil Evaluator 85C ly- Y 10 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1?J U2 Z Af,2U,;77A)6,_fW S744 . -3F 13/
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Theundersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e o of to ph4ce the to operation until a Certificate of om li nice has been issued by the Board of Health.
Signed Date (J
Inspections
3
No. 7-16 FEE
`7
COMMONW ALT14 Of MASSAC14USETTS
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Board of Health, k')1 ('1 I .� 7 MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 4116omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (>,,-Abandoned ( )
by: ! S�
at ( �(i ��'D E
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No.
// dated 46-12-"&17A p /Groved Design Flow (gpd)
Installer �� 1 )� T
Designer: P= SC ) ()� , I Inspector: LLw i Date:
The issuance of this permit shall not be construed as a guar eeat the system will function as designed.
— No. �[� FEE, V
Board of Health, Am
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system
at U d 1 J=am L ig/y O II) --as described in the application for
Disposal System Construction Permit No. (- �6 , dated�jO
Provided: Construction shall be completed within -tars of the date of this permit. All local condi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sul/kin Co. Boston, MA (/ Date '12 D / Board of Health
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