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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6+ / t;L FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, Vi i, QM , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - Acomplete System ❑ Individual Components Location '--0- g d Owner's Name 'i�AtJ�2 Map/Parcel#In Address Lot# Telephone# Installer's NameAp LLC Designer's Name Address© 1 MA Address _ ,� FCS fY1 Telephone# ,47:8 - 40'Z8 Telephone# 4 Ce Type of Building ►"�C"\ 11 Lot Size . ©oc:) sq. ft. Dwelling - No. of Bedrooms �_�«Q C 3) Garbage grinder (141A Other - Type of Building No. of persons 2 Showers (K, Cafeteria (vY Other Fixtures Design Flow (min. required) C ,gpd Calculated design flow ?),�)o Plan: Title Desci Soil I flow provided Z%. �` 5 gpd. Date of Evaluation 1-057-6-+ 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 agree ton a the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date '� ' L- 2Do "1 Inspections Ate' I-Uv7a No. FEE COMMONWEALTH Of MASSAC14USETTS j "G d 6� Board of Health, —� vi MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed W, Repaired ( ), Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the pro ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated 2 J. Approved Design Flow � d) Installer ( 4n o �`. Q e Gln r n e" `r's Designer: Inspector: Date: - _ C] The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. /' U COMMONWEALTH Of MASSACHUSETTS-, Board of Health, \r " , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEES �j /�, (,� Permission is hereby granted to; Construct() Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at � o V.T- n,c S as described in the application for Disposal System Construction Permit No. 61'7 dated 2 - Provided: Construction shall be completed within `h a sof the date of thi�en it. All local con 'tions must be met. Z -� (o 07 J Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health