HomeMy WebLinkAboutApp-Permit-ComplianceNo.����- r r v FEES/
p. C C®MMO LTII Of MASSACHUSETTS �W2
�eqf Board of Health, 7A(ZMO U'iF* , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct (&
Repair( ) Upgrade( ) Abandon() �omplete System ❑ Individual Components
Location 19 Grist MI11 Lane
Owner's Name Anthoney Costa
Map/Parcel# 29 / 73
Address 49 Grandview Drive,Ya
Lot# 70
Telephone#
Installer's Name Dig It Excavation
Designer's Name Sewwtser Eng.
Address
Address
Telephone# 774-722-3789
Telephone# 385-6900
TypeofBuilding Single family house
Dwelling - No. of Bedrooms 4
Other - Type of Building N/A
r
Other Fixtures
Design Flow (min. required)
Plan: Date 4/14/14
Title Proposed septic desi
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
r of she is IT
19 Grist Mil
Evaluator
503
Lotot Size 9,sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
flow Design flow provided
Revision Date 4/ 2 7/ 14
Date of Evaluation
The undersi d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not to place the system in operation until a Certificate of ComRIiance has been issued by the Board of Health.
Signed Date Z
r
Inspections
FEE
No. A�
Board of Health, Ya RMO TM , MA. C
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) /J�6mplete System
The under i;d he certify that the Sewage Disposal System; Constructed ( , Repaired ( ), Upgraded ( ), Abandoned ( )
by: /
at
has been installed in accor a e with the provisions of W CMR 15.00 (Title 5) and the to ed design plans/as-built plans relating to
application No. /� dated . Approved Design Flow gpd)
Installer 6 `—PZ
Designer: 51 L�_� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
�� FEE
COMMONWEALTH OfrMASSACHUSETT
Board of Health, YPIR O t rT* MA_ G`
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebX granted to; Construct Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. ��-=1darted��
Provided: Construction shall be completed within tl �e�reate of this�PeMe-All local con 't;Va/n,
s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadeslowMn Date 4-—,-4Aoard of Health