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HomeMy WebLinkAboutApp-Permit-CompliancerANNIL)U I H HEALTH DEPT. No. II% 1146 ROUTE 28 A VARIkAQ 7,onL • U in, NiA 02664 Ad,,�OMMONWEALTH OF MASSAC14USETTS FEE �C1 1 Board of Health, l , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location Qf✓ Owner's Name Map/Parcel# � Address A d 1� Clete 54 , L Lot# Telephone# Installer's Name B ,S .� C �' Designer's Name Address R-0 . 6Z Address Telephone# b =x, 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 sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided �� gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS c�� C f° N%1 VV Q, �a ru (z1 U i Sct� ►. C % VAV k 1471&1 aiz/ /-Icel�' The undersigned agrees to install the above described. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agreesto not to place the tem ' ope tion until a Certificate of mp 'ance has been issued by the Board of Health. Signed Date o� Inspections N.O. FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, ( A & ' MA. " fir'" CERTIFICATE Of COMPLIANCE / Description of Work: Individual:Component(s) ❑ Complete System The undersigned hereby certify that the Sewage -Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: S C.IG : LSC at (h r .. - e r _ has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ©Z "'/,0 , dated --Z4; ' 6 Approved Design Flow (gpd) Installer C /F f � Designer: ------- Z � Inspector: _ �� Date: _V - The issuance of this permit shall not be construed as a guarantee th the system will function as designed. No. Li �-/ FEE;:. 7,0 COMMONWEALTH OF MASSACII ETTS Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( )IRepair ( ) Upgrade ( ) Abandon ( ) an individthl "sewage disposal system at obi m e "A p e r 4j. i A) - , �-i k A- as described in the application for Disposal System Construction. Permit No. �lU , dated 6 Provided: Construction shall be completed within -t e�of tife date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date e —2— 6 02Board of Health (r!