HomeMy WebLinkAboutApp-Permit-ComplianceNo. o —,)-6
A�JCOMMONWEA .IU ®f MASSACH U§. TTS
4014(0 %a kdloll Board of Health, 1 i 46 R, MA.
4A MR%UCTION
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FEE �+ '
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PERMIT
Application for a Permit to Construct() Repair( )- Upgrade() Abandon() - ❑ Complete System ❑ Individual Components
Location
764 -5w-4 Zjw tO
Owner's Name r,--eS e - -
Map/Parcel#
Address 75/ oG --e-
Lot#
Telephone# S-A!P-W/-
Installer's Name GJ��
Designer's Name G , /7
Address
1s?tiC/l �p�
Address r /t �sd7 �,.1tT`t.e �O
Telephone#
�3� _ p,s^3 p
Telephone#,
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size
sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �l�U gpd Calculated design flow -� Design flow provided gpd
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Revision Date
Date of Evaluation
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 to place the system in operation until a Certificate of�Compliance has been issued by the Board of Health.
Signed / Date - 3,e!!�1s X"
,f �r i• 4 EE Z
No.
COMMONWEALTH OF MASSACHUSETTS Kl
Board of Health, V—fl-
MA. Irl r�v�hr C � A
CERTIFICATE Of COMPLIANCE C " 1,).-t/,s7- i, -%`—t) G•/Z ncc1
e
Description of Work: ❑ Individual Component(s) 4mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (�/+j, Abandoned( )
by:
at
has been installed in accorda9ce with the provisions o_f 310 CMR 15.00 (Title 5) and tbe, approved design plans/as-built plans relating to
application No. ' ,ri -� �? dated �`� & G� Approved Design Flow (gpd)
Installer OCi/t
Designer: G• Inspector: Date:
The issuance of ithis pm'tttiall not be construed as a gu ante, th the system will function as designed.�`��'�
No.� vW FEEc V CJ
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, _ t/1' 1 ` MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (0 ) Abandon ( ) an individual sewage disposal system
at 7 V O c-�'�d't /OG't S'O. ?/e.V,-/?/lJOy%!/ • as described in the application for
Disposal System Construction Permit No. DS(� , dated
Provided: Construction shall be completed within t6f the date oft h' i ,. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date D� Board of Health
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