HomeMy WebLinkAboutApplication - 190 MILL ROAD 9/21/2010 No. g FEE
CO' MONWEALT14 Of MASSAC14USETTS
Board of Health, X41041VIV M.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair Upgrade) Abandon( - omplete System ❑Individual Components
Construct(
Location �� �7l�� Owner's Na✓✓✓m'''e jel.'J/I -/ QC /l,-,
Map/Parcel# — 107A 1— Address NO /!/ &
Lot# Telephone# 1I,, — c 56
Installers Name Designer's Name I
C C✓I/l� l �° ,��G
Address Address v U
Telephone# Telephone# C 1, -3�1 6
Type of Building )6 /))// V 1-21LIRIAJ6 Lot Size 113-116, sq.ft.
Dwelling-No, of Bedrooms UI� �el Garbage grinder
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min. e�1/tired) VO gpd Calculated design flow� Design flow provided o gpd
Plan: Date Number of sheets 2 Revision Date ate
Title Jf/� �l7GI� 5 ,t/Pfl 221,VLLSO'L �S'�SEM Ul�hI? /�(') II�I�L./ell %j11lm l/)Mum
h
Description of Soil(s) _
Soil Evaluator Form No. Name of Soil Evaluator I V 19 i1✓ ; e of Evaluation r 1 a _
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 agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. FEE
COMMONWEAI.T14 Of MASSAC14USETTS
Board of Health, ,MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
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