HomeMy WebLinkAboutApp-Permit-ComplianceNo. �� , /~ 05Y�- " l FEE 0,
X,ffi'Na- COMMONWEALTH ,,,t yht&r. jam' 2-
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Board of Health,SO. YARmobT�i, MA 2 . Q4 "/ ✓%/h
- APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PEPP!/�'][— ir'.; c- Uey;;�4
c A plication for a Permit to Construct( ) Repair(N Upgrade( ) Abandon() VComplete System ❑ Individual Components
, Location
Owner's Name V
Map/Parcel# 1 5 ( /`T "1
Address (a\ - J
Lot# 2q
Telephone#
Installer's Name�hY
Designer's Name bQw�(
AddressD x 1 Y� D
Address
Telephone# - --
Telephone#
Type of Building ER - Lot Size sq. ft.
Dwelling - No. of Bedrooms Z. Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) I -I-0 gpd Calculated design flow ® Design flow provided Z,? • gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees
further agrees t o
Signed
Inspections
Name of Soil Evaluator
Date of Evaluation
the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
n operation until a Certificate1o/f�Compliance has been issued by the Board of Health.
Date � WrI • I 111 Zn 2.
No. FEE
COMMONWEALTH Of MASSACHUSETTS
�l
Board of Health, Y -) MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Ll Individual Component(s) )6 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( 0, Upgraded ( ), Abandoned ( )
by: 1r'- 4vt 1 C N i -t- I U A) � 1 r---( 4' 10 r",J L CJ '
at Gi d a U ;Fn t c-vl i� �J� 6 r 1V1.Ot.)-hi pot -f
has been installed in accordance with the prove ons of 310 CMR 15.00 (Title 5) and the a oved design plans/as-built plans relating to
application No. %� - dated %' �� �--. Approved Design Flow -7� -)0, (gpd)
Installer J !J
Designer: D'AA)1J CA -FE E�a . Inspector: / I il Date:
The issuance of this permit shall not be construed, as a guarantee that de system will function as designed.
No. . < �` A14� l �l^f T FEE ZZ' ZO
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, � :Lmo L74 MA.
r
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) ` ,Repair ( >� Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 0t Y� V 27 V 1 -t -)c,)4 i-1' 1 LkiY tY � l ✓7li� � as described in the application for
l
Disposal System Construction Permit No. 01 - dated
Provided: Construction shall be completed within th =n f he date of this pe it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /- /<? ' 4 ZBoard of Health A-°�