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HomeMy WebLinkAboutApp-Permit-Compliance�-10* / ;�Odj b 60Z COMMONWEALTH OF MASSAC14USETTS Board of Health, *A1- l©UN\-- 1 , MA. FEE 4^00 cmy-) APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(.1/upgrade() Abandon() - ❑ Complete System ❑ Individual Components Location [©Q Owner's Name jcr Z Map/Parcel# b-7 /6q Address q 2?rb,h a - Lot# Telephone# Installer's Name Qmx-`C Designer's Name Address a r Address Telephone# 5 Z _ -)_ a a --- Telephone# Type of Building Lot Size 1173 sq. ft. Dwelling - No. of Bedroomsrpt— 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 Name of Soil Evaluator Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ,!f",ig A-7yeZ S AGB /��/ !!;2,- -' _5^e14'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 n to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed r Date 7 Inspections No. 1�:�IyC" (� Z2 �� FEE COMMONWEALTH OF MASSAC14US ETTS V $ s�5.ao ztaq 7 Board of Health, MA. O'{j4 CERTIFICATE Of COMPLIANCE Description of Work: 1] -Individual Component(s) LJ Complete System � The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired k-), Upgraded ( ), Abandoned ( ) by; %:'rte /`l��i�if> �%l�r�' fir. 5��r�iG S.®�r��C 5 - at has been installed in acco dance with the�rovisions of 310 CMR 15.00 (Title 5,) and the approved design plans/as-built plans relating to application No. dated �/ Approved Design Flow (gpd) Installer Designer: Inspector:Date: -- o The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. Ci 1�i C — Cj —ZZ �1'{ l �t"P { C 0�T+ C,(Zv l FEE ��� •�� Board of Health;` MA. DISPOSAL WSTEM CONSTRUCTION PI�ERMIT Permission is hereby granted to; Construct( ) Repair (�--) Upgrade,( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. /, dated Provided: Construction shall be completed within three years of the date of this permi . All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ) / Board of Health f,. t