HomeMy WebLinkAboutApp-Permit-ComplianceNo. L f `? FEE S V
COMMON4�Ug4aACIXSE��S 1,4
LTH DEPT.
Board of Health, 1146 ROUTE 28 MA.
APPLICATION FOP, DISP0T t ' MMUCTION PERMIT
Application for a Permit to Construct( ) Repairy Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location f I W 1 r %r q �/y�
Owner's Name r 4
Map/Parcel# �Gi�
Address t'�✓�
Lot#
Telephone# Z
Installer's Name G" e- 1&4 -s
Designer's Name
Address /1 &00-0514 DY?
Address
Telephone# ,-Q -3,0,T— .- 8
Telephone#
Type of Building 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)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided gpd
Revision Date
Name of Soil Evaluator Date of Evaluation
d s-Frl 1 v-16- ox- 36
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree not to pla the syste in operation until a Certificate of Com liarl a has been issued by the Board of Health.
Signed Date ��
No. Lf7-3vO
a Board of Health, Y!W 41-- , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: kIndividual Component(s) L1Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Y
Upgraded( ),Abandoned(by: G� Q h C
at \ 44r'M
has been installed in accorddan�c with the pro Bions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application Nom/ 6r r!U(/ //dated// /90' -69 D?Approved Design Flow (gpd)
Installer Arc � �O :JC AP X A
Designer: Inspector:
The issuance of this permit shall not be construed as a guara
Date: 7
that the system will function as designed.
FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
DISPOSAL 11SYST EM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (x) Upgrade( ) Abandon( ) an individual sewage disposal system
at J-7 / YU -,e f+? Rd q as described in the application for
Disposal System Construction Permit No. 0 7 dated �4 /f-14/
Provided: Construction shall be completed within t ars o
� fS the date of this er it. All local conditions must be met.
Form 1255, Rev. 5/96 A.M. Sulkin Co. Boston, MA Date //Q �� 7Board of Health