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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,/d� / FEE COMM©I E LTIT (�A �h�'�M,' LrSETTS d �� i Board of Health, 9 146 ROUTE 28 AMMO tH1DEPT. APPLICATION FOR DISPOSAL SYSTEM M01� �fttOld PERMIT Application fora Permit toConstruct( ) Repair( ) Upgradc(,)� Abandon ( ) - ❑ Complete System 41 Individual Components Location.� Owner 's Name Map/Parcel# �j �j .� Address e, C LoW Telephone# 'O ,.., el Q— G Installer's Na ne — r _G)n Designer's Name 4 C_ fall C_ Address \ LO Address Telephonelk .-.. _ Telephone# GJO — '%'j `z( — `jLS Type of Building Dwelling -No. of Bedrooms 3 Other -Type of Building No. of persons Other Fixtures Design Plow (min. required) //-0 gpd Calculated design flow Plan: Date Number of sheets Title Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Lot Size 1-3/ 1 G 5 sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date 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 not to system in operation until a Certificate o mpli2nce ]lias hee sued by the Board of Health. Signed Date l K /'`-' 'Inspections No. j FEE COMMONWEA' R OF MASSAC-HUSI-TTS Board of Health, �lwr MA.��� CERTI-FICATE SOF COMPLIANCEl> . / ( Description of Work: 1[2) Lrdividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ix). Abandoned ( ) by: C _)- at '� ) l f '� ? ; '`cmc- has been installed in accordiry;e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No �. �� , dated ` C'✓ Approved Design Flow '' (gpd) Installer C nr,r). ,1-' t.�:' ,-.)-,.,_„--_ ✓ Designer: Inspector: " `-"" t Date: The issuance of this permit shall not be construed as a guaranteethat the system will function as designed. t COMMONWEALTH OF MASSACHUSETTS Board of Health, .. , �� MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby ranted to; Construct( ) Repair( ) Upgrade(`-,) Abandon ( ) an individual selvage disposal system at q ) (_ C—) `) , ),,, <C as described in the application for Disposal System Construction Permit No. 0 — , dated Provided: Construction shall be completed �within ' three years of the date of this permit. All local conditions dust be met. / ' I /,� Board of Health . 1.�,m ✓ / v� � Form 1255 Rev. 5/96 A.M.6uIkln Co. Boston, MA Date ?