HomeMy WebLinkAboutApp-Permit-ComplianceNo. - ' `I s� FEE��
l� OU H HEALTH DEPT.
�G`,Gard of Health, I 1 dR R01 JT F Pr, MA.
APPLICATION FO DISPO CTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�-<Abandon() - ❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot# -
Telephone#
Installer's Name
Designer's Name
Address
q
Address 6
Telephone#
Telephone# —
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided 2�O gpd
Plan: Date 10 a! -/ O Number of sheets
Revision Date
Title
Description of Soil(s) -A�u rj, /e1
Soil Evaluator Form No. Name of Soil Evaluator ? Date of Evaluation
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
��too/ not to place the tem in operation until a Certificate of C '
omp anc has been issued by the Board of Health.
rt Signed �![J4.r G the
Date V
Inspections
No. 02 - COMM®NWF-ALT1 Of MASSACHUSETTS FEE
Board of Health,YUA,6��MA.
C EPTIFIC/AT Of COMPLIANCE
Description of Work: O Individual Component(s) -Complete System
The undersigned hereby certify tha the Sewage Disposal System; Constructed ( ), Repaired { ), Upgraded ( ), Abandoned ( )
by: 1T�tJ}
at C1 I 1"n 011V .
has been installed in accord n�je with the provisions of 310 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. "� o , dated1,2--ITQ �. Approved Design Flow (gpd)
Installer /,�/�
Designer: / (__ ///�l� ,�j Inspector: f ate:
s.
The issuance of this pe,it shall not be construed as a guarantee that the tem will function as designed.
FEE
COMMONWEALTH Of MASSACHUSETTS eIr � X-/O/d�
Cj,. `-,Board of Health, , MA.
DISPOSAL SYSTEA CONSTRUCTION PERMIT
Permission is h rebyhranted to,,,C�ristruct epair,( #. Upgrade (L.41"' Abandon (.) an individual sewage disposal system
at 1 i as described in the application for
Disposal System Construction Permit No. C%� —�30, dated
Provided: Construction shall be completed within t��of tl�date of this permit. All local conditions ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 1 -e Board of Health