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HomeMy WebLinkAboutApp-Permit-Compliancea; No. d` �F— FEE V� COMMO V`WE%1 LTWOF 1` ASSA'L_.1t1t�1 &;T; ���0 � 1 �ie� B o Board of Health, r, MA. APPLICATION FOR DISP SAT S"W�'' � ��ARNON PERMIT Application for a Permit to Construct( ) Repair( Upgrade() Abandon() - ❑ Complete System 9Individual Components Location 7/ Owner's Name Map/Parcel# .-. Address . Lot# Telephone# Installer's Name 7`� CO Designer's Name Address Address Telephone# S a �(rj, Telephone# r Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) T �� gpd Calculated design flow Design flow provided gpd Plan: Date /1'!A J/ % y�GOo2 Number of sheets f' Revision Date AJ %iq Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS T� / ,� lnV/l/ The undersigned agrees to insA the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not f thd system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections a No. COMMONWEALTH LTH ®f MASSACHUSETTS FEE J Board of Health, &A` /?�, , MA. 'ell CERTIFICATE Of COMPLIANCE Description of Work: ❑'Vidividual Component(s) ❑ Complete System �Cc �t U/GT ` The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( d ( ), Abandoned grade by: �� 0GU at _77/ / c to C has been installed in accordance with theprovisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to application No. f�� " dated/© �' Approved Design Flow (gpd) Installer Designer: Inspector: G Date: t� t The issuance of this permit shall not be co trued as a guarantee that the system will function as designed. No. [/��(o/'7v�C-(� FEE Board of Health,/m� , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT & Permission is hereby granted to; Construct( ) Repair(., ( ) Abandon( ) an individual sewage disposal 4em at �C-/ C./ a4o L - as described in the application for Disposal System Construction Permit No. , dated Aa z � 6 dGCG�S Provided: Construction shall be completedwithin a,4; �e�rs-of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / !% �� �� Board of Health Zl U ^