HomeMy WebLinkAboutApp-Permit-ComplianceNo, Y'�. �... FEE
COMMONWEALER OF MASSACHUSETTS /I�
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Mftfin"TU HEALiH DAF'
Board ofHeaINP , SVltl.
1146
�11�PLICI�TION FOR DISIMSYA19WH7C,-PI'te
UCTION PERMIT
Application for a Permit to Construct( ) Repair(/�Upgradc( ) Abandon( ) - System ❑ Individual Components
Location
% r
Owner's Name L-1 A N t 0 e.s
Map/Parcel#
tP zp 7
Address'" CRI s' j`, A> -4-rAl
Look
Telephone# 5-06, - 6 O- 1 62/l/
Installer's Namc 1
r o U �
Designer's Name % se" Al
AddressL
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Address S� /1 17 LAit C�7(�
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Other Fixtures
No. of persons
Lot Size sq. ft.
Garbage grinder (t./o)
Showers ( ), Cafeteria ( )
Design Flow (min. required) //,o gpd CMculated design flow .7 .-76) Design flow provided 3
Plan: Date �:'t-A O - G I Number of sheets Revision Date
Tisic
Description of Soil (s) _
Soil Evaluator For No
6 gpd
Name of Soil Evaluator � Date of Evaluation k-? - .20- C/
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire s to not to cc the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed XI/ � � Date aInspections
No.
No. !- W' � - � PEE �P✓
COI`✓IMONWEALIII OF MASSACHUSETTS
Board of Healld,, ✓2 ✓LICK /-// , Al/l. Al
CERTIFICATE 01COMPLIANCE
Description of Work: ❑ Individual Component(s) O�Complete System
The undersigned hereb certifthat the Sewage Disposal System; Constructed L ); Repaired ( ), Upgraded O, Abandoned ( )
at �"? / C -AC' / <-7- I A,+dl Tf / 0--e s ; ✓lit% 41 X4
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) an proved proved design plans/as-built plans relating to
application No. !%� elated -2 -/� ApprovedDesign Flow_--? ` (gpd) I
Installer- l9
8..."Lihl•
Designer: � ,� %�iFi7l� Inspector: f'�"'h� + / Date:
...._.The issuance of this permit shall not be construed as a guarantee that tr}e system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
�1 1-v/ a 'tYzi- , Nbl.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(, )' Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at (� /r? 1 �/ /�.� ���/`� as described in the application for
Disposal System Construction Permit No. � , datedU-
Provided: Construction shall be completed within three_F ns olfihe date of this permit. All local conditions gust be met.
r„ 1
Form 1255 Rev. 6198 A.M. Bulktn Co. Boston, MA Date B021'd of Health