HomeMy WebLinkAboutApp-Permit-ComplianceNo. 4:: �� --� ' �� `fix:. .�� ` /", 11 ree
ICIOMMONIVEALTI110F,MASSACIIUSFTTS �1,,Ia7 `
Board of Health., t „F MA.�// /�*
APPLICATION FOR DISPOSAt-- ''�"F-tai-CC)l�15TT�UCT110N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location IoCfft,
(ti_
Owner's Name
Map/Parcel8
�ZzAddress
15`6_11
Lotdk
Telephone# %7Y 97f-�/' J10
Installer's Name & /l S� x�,.
Designer's Name
Address
��
Address a �,�..-
Telephonetk
3�0�
TelcphoneN' of �../�71
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Oilier -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (trio, requireji)
Plan: Date /
gpd Calculated design flow
Number of sheets /
Design flow provided y gpd
Revision Date
Title
Description of Soil (s) S r e- (-C-
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 3-a e�2 S`e h l (' Aa f,
The undersigned ees to install the above described -Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees too to ce r n6it until a Certificate of Compliance has been issued by the Board of Health.
Signed �` � Date `/0/(/
��,
Inspections
No. V t
COMMONWEALTH EALTil.-ll O t°1 SSA IM11-I1 TS FEE
Board of Health, ' / � ✓0 C, L°°' I-11 _, MA.
C11-111TIFICATL OF COMPLIANCE
Description of Work: D Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: '`)1
at
n
es
has been installed ipnaccorylrce with the provisions o 310 CMR 15.00 (Title 55 and e . proved design plans/as-built plans relating to
application No. (sl YJ . l clated Approved Design Flow (gpd)
Installer -� Y i C c P,- c c ' if' t -17 -
Designer:
P S
Designer: � r �� C f Inspector: �� �/ /�`�/t„,�r, - Dale:
The issuance of this permit shall not be construed as a guarantee the system will function as designed.
pp r
No. C.��;J .r' -""7".t5` p�...l�. t, i rhe
COMMION EAM-1 OF MASSACHUSETTS
Board of Health, 'V1 a '/ "h C'tq I h , M1.
DISPOSAL SYSTEM (CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ( oct 1,/P A6 0-0 -2i k- as described in the application for
Disposal System Construction Permit No. ') -Ji,, dated ��� a(
Provided: Construction shall be completed within ah2X&Vi sh oithe date of this pey nit. All local conditions must be met.
Form 1255 Rev. 5/96 AA, Bulkln Bo. Boston, MA Date —4) Board of Health
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