HomeMy WebLinkAboutApp-Permit-Compliance (Expired)No. s t
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y&9IM0121 ` , MA.
FEE 1,1U-- p_
APPLICATION FOR DISPOSAL SYSTLM[ CONSTRUCTION PETLLILM-11 EIrT.
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - t�Complete System ❑ Individual Components
Location 1 L�
Owner's Name Fi��NG S
Map/Parcel#a� 3
Address $ L
_let'��
Lot#
Telephone# J -f, -p •
'
Installer's Name ��, �.($
Designer's Name E
-t Asst) c
Address �:p ew M .Mok
Address A N
Telephone# ED&3 f
Telep e
Type of Building KJE. ( � L V l>Ai— `-
Dwelling - No. of Bedrooms �i-
Other - Type of Building
Other Fixtures 'W ODS
Design Flow (min. required) gpd
Plan: Date -4, 1 T� - 14--- Number c
Description of Soil (s) � -
Soil Evaluator Form No. it Name
DESCRIPTION OF REPAIRS
—__L.. i
Lot Size a& -T' sq. ft.
Garbage grinder ( )
No. of persons Showers( ), Cafeteria ( )
flow � Design flow provided `%" /n!7 gpd
Revision Date
Evaluator ") Date of Evaluation,3— L< —
The undersigned agrees to install theove escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur s o to 1 to operation until a Certificate of Compliance has been issued by the Board of Health.
Sign Date - 173 TIS
Inspections
Fel
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No. J FEE (f� �✓ V
COMMONWLALT14 Of M ASSACITUSETTS C -,� 7-�
Board o Health ARIA0 Q 1� MA.
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CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) .0 Complete System
The undersign ed hereby` cert that the Sewage Disposal System; Constructed (�(', Repaired ( ), Upgraded ( ), Abandoned ( )
by: �l /w
has been installed in accordance with th� provisions of 310 CMR 15.00 (Title 5) and th roved design plans/as-built plans relating to
application No. I d ted �� . Approved Design Flow •/(gpd)
Installer 7, Wz
Designer: J . a/. U h4tfddL61 Inspector: Date:
The issuance of this permit shall not a construed as a guarantee that the system will function as designed.
I_
No. _J� �(' �fj FEE
COMMONWEALTH ®f MSACHUSETTS
Board of Health, ' &MOOTW , MA.
MSR®SAI. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at
Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. _ 14-> �' 9 '
Provided: Construction shall be completed withi+ f the date of this per it. All local conditions must be met.
Form 12555 Rev. 5/96 A.M. Sulkin Co. ChadeslownMA Date A E` Board of Health
A , `