HomeMy WebLinkAboutApp-Permit-ComplianceNo.� FEE
COMMONWEALTH OFMASSAC14 SETTS Z4,
Board of Health, Y,# /F , MA.
APPLICATION FOP, DISPOSAL SYSKM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(P."Upgrade() Abandon() - ❑ Complete System 5146dividual Components
Location j'j'j llple ff /,�/t�Dmlt- �'� y,a�R
Owner's Name D5,Z /-T— 5',4 A.- 5'
Map/Parcel#
Address N A00k
Lot#
Telephone#
Installer's Name c Q
Designer's Name
Address -� s'� �A, 5 IAI_ frAf1°
Address
Telephone#
Telephone#
Type of Building / ` G L/S F Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS A 14 /,-L,
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not to place the syste ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Z
Date / —,0 Y
Inspections
No. d9 -�) �?
COMMONWEALTH OF MASSAC14US ETTS
Board of Health, �w /< , MA.
CERTIFICATE OF COMPLIANCE
FEE A ,
//WIV z6oul
Description of Work: M Kdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Ir, Upgraded ( ), Abandoned ( )
by:�1 / T 014fY/ (7 0 � .5 6 IV 7 -
at /1*R° a /P O4 IP 00k- A10 2) !.. ` �—,4
has been installed inc_ordan with the rovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No 0� o , dated 9'-% f2 -t. Approved,,,Pesign Flow (gpd)
Installer
Designer: Inspector: a ,: F� en ,'�� Date: le,
The issuance of this permit shall not be construed as a guarantee that the system wiHT&nction as designed. /
No. 7 / ! / Q- 4,1_60
COMMONWEALTH Of MASSACHUSETTS
17
FEE N, ` ,
Board of Health, 1--,4 x, MA. � G
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissionishereby granted to; Construct( ) Repair ( #Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 1 6 M f ,f l a l? tgR 001-r-AA0.2)1,V ` ( `i IV as described in the application for
Disposal System Construction Permit No. 0-1 Q, dated h / 07 .
Provided: Construction shall be completed within thrr s`
p .�e..��-,..ups f the date of this p it.
�A)ljl�local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date CJ / (/ Board of Health C..��