HomeMy WebLinkAboutApp-Permit-ComplianceNo. (✓ FEE '.to
COMMONWEALTH R H�&%CdJJ4,FTS
Board OfTlealtht1,48 ROUTE 28 MA.
AP
PLICATION FOR DISI�8����a W ONSTRUCTION I ERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(' Abandon ( ) - L'TComplete System ❑ Individual Components
Location ' orf
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Owner's Name
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Map/Parcel#
Address
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Lot#� G
Telephone#
O „3
Installer's Name IJ A_���'
Designer's Name
Address \
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,;�ddress
C
Telephone# Ae_Telephone#
Type of Building %CG..1. Lot Size
Dwelling - No. of Bedrooms �l
Other -Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow -} Design flow provided gpd
Number of sheets Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator- Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the abo escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to t tolaceeCi!- tim m p eration until a Certificate of Co�lian y has been issued b the Board of Health.
Signed .4' P } Date
Inspections
No.•`.w• ✓11" SCC
COMMONWEALTH OF MASSACHUSETTS �/ �I � ��� �
Board ofllealth, "d ) ®� wy ` IWA.
CERTIFICts) ATE OF COMPLIANCE
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Description of Work: 0 Individual ComponenS"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( );'Abandoned ( )
by:°'pa y f y )7tte ° A P
at LEI C,-9` / ,,4 e,, ^°,.) /.A{{ 4"Y-tt $'"'°'�' 46$--°.1 1' "..a."'i.✓"`): S., ` G':%. '"�,"".�' as-�«".y e.m^/"°:.',"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. -- � dated r°�� '"'� `� e' ,:rA1....Approved Design Plow <"� ...(gpd)
,+ T'
Installer (d,�°,�"`m at�..�" ..• r' �""y Jr�.�°?✓'.r"`r''+€:...,+° ,, 11
Designer. i Asa F`` Jr'P a ''.%'.�`'>•'t !'� Inspector:)' dkt fr°%��`' is +' �; � t, �_ Date: r`�+r w. :f`.' °2�_
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No e,� ) FCL
COMMiONRVEALTII OF MASSACHUSETTS
Board of Health, �,�l /7 / -/(> upr` IVLA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ("1-Y Abandon ( ) an individual sewage disposal system
at A97 as described in the application for
Disposal System Construction Permit No. dated rr '
Provided: Construction shall be completed within-thre! years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Basion, MA Date r e'' g021'd Of Wealth '°`"='�^fi "' L/.%`.✓