HomeMy WebLinkAboutApp-Permit-ComplianceNo.
FEE
T 1n I 3 L
r� Board of Health, Qa/ jWl-!�l /4- MA.
&,L 1A15A
LICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(lUpgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location z 1/ W,
Owner's Name
Map/Parcel# 9 `7 G
Address
Lot# 14
Telephone# '
Installer's Name®r ®� ��>''
Designer's Name
Address (-' T� r �%
c!/ v` I
Address �3'� Ie472 - &ems v �
Telephone# 7
Telephone# 3"01Z�
Type of Building �6� %��%?�� Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 330 Design flow provided — gpd
Plan: Date 73/100 Number of sheets Ia Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
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 oto ce e s stem in o 'en -until a Certificate of Compliice has been issued by the Board of Health.
Signed Date
Inspections
No.-fFJ- FEE
COMMONWEALT14®F MASSAC14USETTS
Goar of �alth, f)% �� %—� MA. G
YYY
4CNCE
Description of Work: Indiv�dtto one Co le%lSysem�
/(�
The undersigned hereby, @rtify� 't the Sewage Disp A System; Constructed ( ), Repaired (t�Upgraded ( ), Abandoned ( )
by: _ Of i`GLO /,d.ZAp f &
10 A
has been installed in rdaijce with the provisions of 310 CMR 111
application No. ' dated �� /l% ' ��. Approved
Installer OW-10Ld
Designer: �(�/ �`�c4 Z� i�iSrr�i Inspector:
The issuance of this permit shall not be construed as a guarantee that
rid :the approved design plans/as-built plans relating to
(L' &IC&X&4 Date:
system will function as designed.
No. YJ 3aAVZ G Er,i7/
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Aej-�Iw , A, MA.
FEE
DISPOSAL SYSTEM CONSTRUCTION PERMIT
r.
Permission is hereby granted to; Construct( �)/ Repair (VII Upgrades(, ) Abandon( ) an individual sewage disposal system
at 2-7i�`%i�/7 rUt. /Qr�P�/:1/OiI as described in the annlication for
Disposal System Construction Permit No. qF , dated
Provided: Construction shall be completedwithinthree years of the date of this permit. All local co9ddiiti/ons mu be met.
Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date