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HomeMy WebLinkAboutApp-Permit-ComplianceNo. L� . • FEE \ , /Z) A4:�e ? �F-7,f IlPcfe�, -/ COMMONWE-ALT14 OF MASSACHUSETTS Board of Health, � AR,*n o, -mi MA. /11"UPPLICATION Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) - '''Complete System ❑ Individual Components Location Owner's Name Map/Parcel# s ` Address) ( .�e H{ 2S Lot# Telephone# VL Installer's Name S ; Designer's Name Address P t � Address T10. 12 ` VEk\nio�DT Telephone# © Telephone# S R _`VCAkCk0- Ca Type of Building ie -,.\6ec1- Lot Size (214 sq. ft. Dwelling - No. of Bedrooms {W_9— (-4) Garbage grinder (II4 A Other - Type of Building I�CI�I F- No. of persons 4- Showers ( q-, Cafeteria (t y Other Fixtures LAU A mPy �\'TC1��+�1 C]iw1iG 1 LAUD,3y Design Flow (min. required) 44M gpd Calculated design flow 446 Design flow provided 44 4r gpd Plan: Date -4 0,93 Number of sheets I Revision Date Title-i2mMVA SAAR Sy-, C �C O -e 59� ( . %=S Description of Soils)_ 1�aSe�Pr bkor, Soil Evaluator Form No. Name of Soil Evaluatorla'1 "o"AR)y Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS e --Qp� No P�csc� The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and fur o ce in o n until a Certificate of (Compliance has been issued by the Board of Health. Signed Date Inspections (_0 No. - FEE UI .. i COMMONWEA T14 OF MASSAC14USETTS VBoard of Health, MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 'l -Complete System The undersigned hereby cgiify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (V , Abandoned ( ) Y at has been installed ip accorda ce with the provisions of 310 CMR 15.00 (Title 5) and tlje�pproved design plans/as-built plans relating to application No. �G��7 !� d��6 � � .Approved Design Flow �`� (gPd) Installer L' S Designer: '( ,,afiyw Jltt�-f Inspector: M±tK R S Date:fe" The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No.� �05 FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair ) Upgrade N -4 ---Abandon ( ) an individual sewage disposal system at ` `� 1 C� �(4 as described in the application for Disposal System Construction Permit No. 6"'F -1%9 dated U Provided: Construction shall be completed within thars of the date of thi n t. All local condi 'ons must be met. F Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date��� Board of Health