HomeMy WebLinkAboutApp-Permit-ComplianceNo L FEE
S11 Board of Health c 6 `>:.° MA
Application for a Permit to Construct( ) Repair( )-Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 6REW C Ob
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Owner's Name CV.P- �p
Map/Parcel# MAP 14
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Address
Lot#
Telephone#
Installer's Name
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Designer's Name W UM ,- A:&505,
Address 0
,�� /k j �� VKh0"+S
Address �OX .�� r, l 1LL� MA
Telephone# -
. 0 2-8b
Telephone# 3
Type of Building i D1 -4771 A-L &j 6L4 > 1 W4 Lot Size /(0O0 sq. ft.
Dwelling - No. of Bedrooms �' Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures o1
Design Flow (min. requ' ed) 4 y D gpd Calculated design flow 440 Design flow provided '7 %3. 4o gpd
Plan: Date Gi 1 Z- D Number of sheets Revision Date A& AVE
Title
Description of Soil(s) `TEST lyL,57 Lh6
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install tke above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to place tholg4stem. in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date (b ' (�
Inspections /� ��%'� �rl�_� dL>` — /OLLL/7�CGi 67 " SL!ll1�Q®fGJ
No. COMMONWEALT14 OF MASSACHUSETTS FEE /
Board o Health i�r►toU?R MA. �6
f ,
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby c ertify that the Sewage Disposal System; Constructed ( ), Repaired (K/Upgraded ( ), Abandoned ( )
by:
at
has been installed/i� accgrAkL e with the}�rovisions of UO CMR 15.00 (Title 5) and)e proved design plans/as-built plans relating to
application No. Q! �" �, dated / 6'Z� d S . Approved Design Flow(gpd)
Installer J A r-A C_$40 W-&V-
Designer: WELLM + A$S0 C . Inspector: ` Date:
The issuance of this permit shall not be construed as a guarantee dat the system will function as designed.
No. U� J' 4K FEE �• V c�
COMMONWEALTH Of MASSACHUSETTS 7t
Board of Health, -I �► � u Tl� MA.
DISPOSAL SYSTEM, CONSTRUCTION PERMIT
Permission is hereby granted to; nstruct( ) Repair (✓) Upgrade( ) Abandon( ) an individual sewage disposal system
at 9 as described in the application for
Disposal System Construction Permit No. �)_ dated
Wwj
Provided: Construction shall be completed within thTi e_e ss of the date of this pe it. 1 cal conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, M\/A%Date �� Board of Health �-