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HomeMy WebLinkAboutApp-Permit-ComplianceY... _ ®%'bPl�dS• f'd u 191 HEALTH @.�E a . 'FACUTE,23 FEE �OMM8 '-UNWENAC IIUSET TS ( G Board of Health, CONSTRUCTION , MA. APPLICATIO���1 FOP DISPOSAL SYSTEM '1. STRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location 4 6 AS VA. Owner's Name e t Map/Parcel# 78 Address Lot# Telephone# Installer's Name o $BST �J . ©U� �d . Designer's Name G Address G R �2 Address 3 Telephone# Telephone# 3 g . 21+25 Type of Building ZI) to Ef1i,c! G- Lot Size Dwelling - No. of Bedrooms 3 Other - Type of Building No. of persons Other Fixtures sq. ft. Garbage grinder (go Showers ( ), Cafeteria ( ) "Design Flow (min. required) 330 gpd Calculated design flow .330 Design flow provided 349.Z gpd Plan: Date Number of sheets 014 E- Revision Date �T Title Description of Soil(s) OFF R , Soil Evaluator Form No. 16 8¢ Name of Soil Evaluator %Zb :])d/ /W.# Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS �R r= aL Acp-- S 1*4 S The undersigned agrees to in the above described. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pI. a system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed A /, z Date /0- (5k 1 Inspections Q No. to ,('� �T�}�j j� ,(� � T FEE COMMO1V` VV A LT14 OF MASSA 14USETTS Board of Health, , MA. ! CERTIFICATE OF COMPLIANCE Description of Work: A13ndividual Component(s) ❑ Complete System The undenneed hereby certify that the Sewage Disposal System; Constructed ( ), Repaired pgraded ( ), Abandoned ( ) by: / at y% C� /'✓� / C 6N 0 La o a0 has been installed i accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �1' �Z•� dated /DApproved Design Flowf)!f_�-�,(gpd) Installer Designer: /-/gp Gii Inspector: ate:117 �S- The issuance of this permit shall not be construed as a guarantee that th system will function as designed. No. �` V C� FEE�� COMMONWEALTH OF MASSAC14 SETTS rj Ch Board of Heealth, . ye!x— 4;y-► , MA. DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(( Upgrade ( ) Abandon ( ) an individual sewage disposal system at c( 6 e-/✓ /f / C .f 4 r L t r .tt as described in the application for Disposal System Construction Permit No. J�, dated C� Provided: Construction shall be completed within three years of the date of this pe it. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /d 14 AT Board of Health '