HomeMy WebLinkAboutApp-Permit-ComplianceNo. -12-k Zi r 1/f Awv� FEE'YA�Sr
T.
Board of Health, N 2.1
APPLICATION FOP, DISPOSAT- 9"NNTIC, BMW CTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeJ/j/Abandon( ) - ❑ Complete System • ff-,.- vidual Components
Location -
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Owner's Name An -r\ k`r-Q
Map/Parcel#
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Address Q, Flout 1�dC K rWVAk. 614
Lot#
Telephone#
Installer's Name
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131, . knnL
Designer's Namer-L
Address j
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Address
Telephone# X71
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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) gpd Calculated design flow 4150 -fa— Design flow provided '1' 72 gpd
Plan: Date Number of sheets Revision Date
Title -//��
Description of Soil(s)NJ�r_-�
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedfY1r. Datecell-
�a Inspections
No. Jr/
Description of Work:
by. Hca ri
at c�. I
has been installed in
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COMMONWEALTH Of MASSACHUSETTS. f- f(
Board of Health, " IQ y1n`r � '�\ MA.
CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) 3 -Complete System
)y certify that th)e. Sewage Disposal System; Constructed ( ), Repaired O, Upgraded4a!Abandoned
_ 13, f
;cor ane with the provisions 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
-41> , dated 7 . Approved Design Flow 6 gpd)
Installer i x r % �2 SA
Designer: fl rr + Inspector: `! ( Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, jr' � G ' i� MA.
j
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ), Upgrade( Abandon ( ) an individual sewage disposal system
at ,� F l G -f` f t ,) d <-1 or -114 as described in the application for
Disposal System Construction Per No. 06 dated � �'` NN
Provided: Construction shall be completed within three -*ears of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date % 4 `� Board of Health
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