HomeMy WebLinkAboutApp-Permit-ComplianceNo. LD 1 P-- 1 U— 00 / -Z-3 FEE 46 V 41
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Board of Health, I s uu� o� �, MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUC RM �
Application for a Permit to Construct( ) Repair (✓ 4gradeO Abandon( - ❑ Complete System UMMdividual Components
Location �,S J o - �yQ.
Owner's Name
Map/Parcel# PO
Addresy,?aF
Lot#
Telephone# 9-7�— 6
Installer's Name
(4�-fola
Designer's Name ��--
.G �I E ! a
Address _
SG�
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Addres
lames a
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Telephone# S;
Telephone#�^oe
Type of Building Lot Size lam, -7 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) O gpd Calculated design flow Design flow provided --70z�, 7 gpd
Plan: Dated J /3/�'/.,P Number of sheets / Revision Date
Title z D`'Q�,•ne� gi�'e G `J
Description of Soil(s) _i�rusr� %C'ocrv�•� ���^
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ril SG
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 !Q place the system in operation"until a Certificate of Compliance has been issued by the Board of Health.
• Signed a-��'� �� Date
M
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� ,FEE J5COMMONWEALTH Of MASSACHUSETTS. v�\Nw
jLtFL
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: El"Individual Component(s) ❑ Complete System- i %'� b� Cej�-
The undersigned hereby certify th t the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned ( )
by: f'_s
at
has been installed in/a�ccordanc th thejrovion of MR 15.00 (Title 5) and the
application No. 1f ` dated (a roved Design Flow
���/�
Installer `^r-c=' i- — ' 14
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F
design plans/as-built plans relating to
Designer: L- +)61 W �.�{- iLi NJ f }�,L S Inspector: Date: _
The issuance of this permit shall not be construed as a guar` tee that the system will function as designed. .
,
No. u N c-4 8-33 J CPrp c COD Sc--p-ri c scywk cE�5
Board of Health, MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
FEE .00
c 2-g52-
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at ��' �w� ///�! / f as described in the application for
Disposal System Construction Permit No. dated .
Provided: Construction shall be completed within`tlT tJedate of this permi 1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date✓ / Board of Health