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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE.'®' (.FV CO'1[MONWEA LT14 OF MASSAC14USETTS l� Board of HealthYP.RMC:UTH HEALTH DEI�. �Wf?PLICATION FOR DISP06A%4WVA*(0*4RUCTION PERMIT 1146 ROUTE 28 Application for a Permit to Construct( ) Repair( ) 41"Complete System ❑Individual Components Location j- j� V-r ,✓(, Owner's NameVA�161-f'�- Map/Parcel# �� f%� Address ram" /-%,Ij 7j,.f 4 A/V-t..- Lot# Telephone# jP& - pS = -Y 5-�p Installer's Name cp Designer's Name Address iJ': Address -3 ✓ �� Telephone# _ __ _ 0/"0 61 1Telephone# clr�,9� _ Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ 64,t Ih-,i No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures 41 Design Flow (miyyn. required) �� gpd Calculated design /flow _� Design flow provided gpd %` Plan: Date " ou ©� Number of sheets 7 Revision Date Title Description of Soil(s) C0.9tyC Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS � �r /5�/ l`�4� jly,/7 c- o %C The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr s to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �. (�U�^ GO Date /—a * ' �/ Description of Work: ❑ Individual Component(s) Z06omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( ) by: CO 1-/yL ,at has been installed in ccordance with the provisions of 0 CMR 15.00 (Title 5) an the roved design plans/as-built plans relating to application No. it �-iz dated `��. � 0Approved Design Flow (gpd) Installer I'4 f?��J :;�- `%U/`co Desig r: of Inspector: �wk"Date: 2- % The issuance of this permit shall not a construed as a guarantee that the system will function as -designed. No. U Y -- -- - FEE COMMONWEALTH OFMASSACHUSETTS Board of Health, - ZG/'''d'nl dy/ DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( )' Repair(v< Upgrade( ) Abandon( ) an individual sewage disposal system at � d o "441N f as described in the application for Disposal System Construction. Permit No., dated —� Provided: Construction shall be completed within " " o� the date of this permit. All local con4ditio s must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA j to Board of Health