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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE 0 AS - TLOOFL,� M SACHUSETTS '0 /jjWCOMMONWL% TH HEALTH DEPT. S�j�'Board of Health, 114E RIC UTE 2.3 MA. C;1 VA . APPLICATION FOR DISPA 'MMM9MUCTION PERMIT Application for a Permit to Construct( ) Repair( N. Upgrade Abandon( ) Complete System ❑ Individual Components Location L -ff LE bj (PEA L � Owner's Name � Map/Parcel# 1 Address MAJIF-E-T Lot# Telephone#56 O %463- �� Installer's Name Pi<M ���+1J t` c Designer's Name ]>VA1 CPPF—Q Address 313VrnRoCK-RD Address -lq M)41 fq ST VngffloTff Telephone# M19- 2-5 _ Telephone# - ,.. Type of Building 'Res JJt+[+ a a 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 Plan: Date % /'% © Number of sheets Title Description of Soils) Soil Evaluator Form No. Design flow provided_ gpd Revision Date Name of Soil Evaluator y:y1/L Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS tiC� fr,�(I S G- i/ 5 r j�Lj The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a" t(lace th em in operation until a CertificaVMVas been issued by the Soard of Health. Signed"U/�� Date Inspections No.y / ~ f� � FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, �l rlu t i� �u MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) R Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �,Abandoned ( ) by: �I`7� t ' (�►�l j f l Zi at f.1`-�2 LITME I)%Pl has been installed in acco>�dan with the ro ' ion/hs� 0 310 CMR 15.00 (Title 5) and t proved design plans/as-built plans relating to application fNo. _ Z4 dated ' . �lJ- Approved esign Flow `i/ (gpd) / Installer E� b'1l 0,f) A/ 1 R Designer: 1 DA)Aj colD -.-. Inspector: Date: V The issuance of this permit shall not be construed as a guarantee that the system wiliq nction as designed. No.� COMMONWEALTH OF MASSAC14USETTS Board of Health, MA. DIPOSAI. � Y�TEM CONSTRUCTION PERMIT Permission 'ijs hereby granted to; Const'rruct( ) Repair( Upgrade (L-11" Abandon ( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No.� date Provided: Construction shall be c mpleted within et t`e y"� ea s of the date of this pe; it. N1 local condition ust be met. wk.:/'C-��� Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date/v - U � Board of Health AIC 7S+