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HomeMy WebLinkAboutApp-Permit-ComplianceNo. --� �—� �r / 76X ,,- a A FEE J COMMONWEALTH OF MASSACHUSETTS ABoard of Health, 'hA4N a - a QA1 MA. ±�L� APPLICATION FO UDISPOSAL \P\AL SY\LM CONSTRUCTION \VCTIPE M IT t A plication for a Permit to ConstructO Repair(�gradeO Abandon( - ❑ Complete System ❑ Individual Components rJ P' Location Q11 -Nm 1-� o z=V �9- �Z p C�,-,k Owner's Name Map/Parcel# S 17Z Address SIB Lot# 1^Z Telephone# Installer's Name Designer's Name Address 3 �® �� �� c� Address Telephone# p Telephone# Type of Building F--: X \S Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator Lot Size sq. ft. Garbage grinder( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS {�� � ;1c ��� - A A i 1J C�o`a.^ 1`� e via o c a� `1 The undersigned agrees to installth�dped,Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further afire n p c tl a on until a Certificate of Compliance has been issued by the Board of Health. Signed �l Date .q ^ UL , o Qn Inspections No. t/ COMMONWEALTH OF MASSAC14USETTS Board of Health, �.fl uV\o ��� MA. FEEyv �';-off �t .V u Description of Work: U<diidual Component(s) ❑ Complete System U" The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-r,1 ( ), Abandoned ( ) by: (-'-, '12> C C' "-\ c ) at V2�, 0- �-, t-, -:_ � e`_ v o ck CD 0 has been installed in ac ff or&3n�je with the Provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. 9 - Ut/, dated G `�� !t�. Approved Design Flow ( d) Installer CA`s lk"ef �C%�l C/�/' % l Designer: Inspector: Date: The issuance of/this permit shall not be construed as a guarantee that the system will function as designed. No-06-60 COMMONWEALTH OF MASSAC14USETTS Board of Health, ��' cz VNO , M. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair (Upgrade ( ) Abandon( ) an individual sewage disposal system at 8� �` `� Q. C �-- © o. J� ` ArZ.Yy�o�`c�� �' as described in the application for Disposal System Construction Permit No. 0 6 k) , dated -F` e 6 Provided: Construction shall be completed within of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date1 U U(- Board of Health