HomeMy WebLinkAboutApp-Permit-ComplianceNo. l/� � � %� 4�l FEE 5 '!9U
C®MM®NWEALT14 OF MASSAC14USETTSPr
Board of Health 14C AGUTE 2-8 MA.
Application for a Permit to Construct O Repair Upgrade O Abandon O - ❑ Complete System ;dndividual Components
Location
/ oZ COC/lf
Owner's Name
hV J
Map/Parcel#
Y) J ICJ
Address
�nd� ���
Lot#
Telephone#
Installer's Name
_e C;L,,A CSD v�
Designer's Name
Address.?
ddress f/�tegj ��L f/ lin/
Address
Telephone# _j -010F -
U
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS i0A �C ri✓�° �%y �'1 V ����G��
-- -4 u% 7 _P� Ot ce
gpd
The undersigned agrees to install the above described.Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to pla a the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed /' Date -U
ep-
Inspections
No. `� .O �{�� FEE"
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /cis ),, j / MA. f
CEPITIfICA Of COMPLIANCE
Description of Work:.' U Individual Component(s) ❑ Complete System
The undersi ed hereby certify that the Sewage Disposal System; Constructed ( ), Repaired�Upgraded ( ), Abandoned ( )
by: &,-7- O Cum' Co ; 4
at �% % 5 !g „" �� er 04
`has been installed iA accor e with therovisio s of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. %� dated �� -Z� Approved Design Flow (gpd)
Installer ' �` 6� -l'�'�' I -C,
Designer: Inspector: —T Date:
The issuance of this permit shall not be construed as a guarantee that the system will f1wction as designed.
No. r�C3 ' / U'�( FEE
® l�®NLTOFMASSACHUSETTS .A rte` V11 7
Board of Health, 0(.°
MA.� AV
DISPOSAL SYSTEM CONSTRUCTION ERM1.
Tb
Permission is hereby granted to; Construct(), /Repair( ) Upgrade ( ) Abandon( ) an individual sewage disposal system,,.
at %'f .��.f4 �'` y� A as described in the application'for
Disposal System Construction Permit No.
Provided: Construction shall be completed /within three years of the date of this permit. All local coinddiittions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � Board of Health'