HomeMy WebLinkAboutApp-Permit-ComplianceNo. 12--/ 4 �-
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/-,;P /A6OGP5// Board of Health, a 14s ¢ d o,, ? r E est , MA.
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9-7- :WL*PPLICATION FOP, DISPOAF����TCTION PERMIT
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Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location
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Owner's Name
Ak-:)LA
Map/Parcel#
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Address
r W6 4, fl Y V1."—
Lot#
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Telephone#
Installer's Name
\' v e
A411
Designer's Name
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Address
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Address
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Telephone#
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Telephone#
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Type of Building ��� ' �1 \ Lot Size
5
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided �` gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil >valuator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATION^ S \` \ Y� CX 0 4-k 1-' P + h
J .5� 1tF�.cnv c% \h �t �'�� rs -s- n .
The undersiened agrees to install the above described Individual Sewage Disposal System ' accordance with the provisions of TITLE 5 and
further agrtit
f to pl t in o era on until a Certificate of Com fiance h been issued by the Board of Health.
Signed Date ��
ti / /
Insy;�ections �'• � _O 90;A
/l S 04- %y 1,06 A41
`G'�.Ln��
No. v - /(O / �'1� FEE
COMMONWEALTH OF MASSAC14USE TS
LlBoard of Health, r'Wm MA.
CERTIFICA ®F COMPLIANCE
Description of Work: kridividual Component(s) ❑ Complete System ��
The undersigned hereby certify that the Sewage DisposaI'S(�stem; Constructed ( ), Repaired K, Upgraded ( ), Abandoned ( )
at
has been installed in accordce with the provisions of 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application No. 10 _ _3,//9 dated `%M^C� ApprovedD-esign Flow (gpd)
Installer <�_ �_\ f - _�_ C Y ` g , _
Designer: 1)'�' W `� Inspector: % Date: I? _41_1 d
The issuance of this�ermit shall not be construed as`a gu antee that a system will function as designed. - No. L� �' 1 C!/, G/�� / FEE 1CJ
COMMONWEALTH Of MASSACHUSETTS
Board of Health, `� �`:` MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at ���\ r� w �� 1�n�±U �- as described in the application for
Disposal System Construction Permit No.dated :7- JZ _1�12;,
Provided: Construction shall be completed within dv_e s f he date of this pprim} it. All local conditions must,,15�0 met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -T_%/ 6�--Board of Health.
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