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HomeMy WebLinkAboutApp-Permit-ComplianceNo. L FEE Board of Health, 1146 ROUTE 28'd IAA APPLICATION UGDFOR DISPOSAL SYSTEM STEM CONSTRUCTION T� CTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location S Al-pleEzo5 4W, Owner's Name Map/Parcel# Q 94- Address Lot# Telephone# Installer's Name E� Designer's Name 7. Address -S� NA A L Address z6 Telephone# M ?� - a, (o Telephone# S-b g 38S ,Z4Z6- Type of Building ���iF f �� /✓ cZ_ Lot Size Dwelling - No. of Bedrooms 3 Other - Type of Building No. of persons Other Fixtures sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Design Flow (min. required 3 O gpd Calculated design flow 3 3 6 Design flow provided 3 3,2 , z gpd Plan: Date ,i. / Number of sheets o Nam- Revision Date Title Description of Soil(s) S E r PZ Sol Evaluator Form No. .Z463 Name of Soil Evaluator _T. JA��x�eauL�T Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS E C2GAGF—: Ca e_0 /� The undersigne agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees of to place em jperatiori"until a Certificate of Cotli ce as been issued by the Board of Health. `Signed Date rF ti kispections . No. 0 2 ` FEE i "y' C✓ Board of Health, �T , MA. CERTIFICATE OF COMPLIANCE E Description of Work: ❑ Individual Component(s) Xcomplete System The undersigned hereby certify that he Sewa' e, Disposal System; Constructed ( ),,Repaired k Upgraded( ) , Abandoned ( ) rc- by: at A 4\G K-VIS /-1114ti - - has been installed in accordance with the provis ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.dated�A proved Design Flow gpd) Installer /�' , 4 1 q/ / Designer:v 141 ��- Q U L T Inspector: Date: d The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. V �J -- ��/�f~i /iIT t�/�/ FEE Board of Health, MA. DISPOSAL SYSTEN(CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) RepairK) Upgrade( ) Abandon( ) an individual sewage disposal system at �o �� ��� -s as described in the application for NW Disposal System Construction Permit No.6 , dated ro --r�� Provided: Construction shall be completed withinnj }'fin o the date of this permit. All ��jlocal /conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date( -)— /©2-soard of Health ✓�"-�