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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1500C- te-0 L fLI di � � r / FEE t COMMONWEALTH Of MASSAC14USETTS Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(Ii-lul`pgrade ( ) Abandon( ) - Yd Complete System ❑ Individual Components Location �j Cee Owner's Name Map/Parcel# 0,e- Zinel Address 215 Fr M 1 f 4 Lot# Telephone# -I �5 1415- Installer's Name U o Designer's Name o caop.n S Io c. Address11iV30 dL a Q esscrig � '1 a f �1'� Telephone# 'N --7 & Telephone# —o R_ a_ Type of Building �io�si% ���<�S/ Lot Size /4 7 3 sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) 3 © gpd Calculated design flow Design flow provided 3 6 gpd Plan: Date 141115 c.9111 --p Number of sheets t Revision Date Title'5— rSr;�e Description of Soil(s)— -5,:7 -1,--Z 3 © < Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Z. 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 place the system in operation until a Certificate off Compliance has been issued by the Board of Health. Signed ��c:- �� Date No. FEE 160 �� tt COMMONWEALTH OF MASSAC14USETTS Board o Health MA. C.ERTIFI�YE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 1�3 Complete System The undersigned hereby certify.thX the Sewage Disposal System; Constructed ( ), Repaired /Upgraded ( ), Abandoned ( ) at has been installed application No. J Installer with the provisions � CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated ! A) -4L t° Approved Design Flow --r 314;- (spd) — Z s Designer: f t/L. L v`'w'Y/ nspector: ZA ( k J t. -Ke r' .. ° 1Jate: The issuance of this permit shall not be construed as a guaoat a that the system will function as designed. -X 557: Q No. l`. o iyc `�( c`,—ojj.y y l C 7 C.. `) V S FEECOMMONWEALTH OF MASSAC14USETTS CkA�--,2-30�, Board of Health, MA. DISPOSAL SYSTEM, CONSTRUCTION, PERMIT Permission is hereby granted to; Construct( ) Repair(—�Upgrade ( ) Abandon( ) an individual sewage disposal system at c .�<'c'°>�'" �`���t fJ as described in the application for %/ f Disposal System Construction Permit No. dated Provided: Construction shall be completed within th ears of thedateof this permit -All 1�ca1 conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health