HomeMy WebLinkAboutApp-Permit-ComplianceNo.
/I 42Y COMMONWEALTH OF MASSACHUSETTS
Board of Health,
�,'/APPLICATION FOP, DISPOSA109MT04TONSMUTION PERMIJ
FEE
Imo' rl �
App kation for a Permit to Construct( ) Repair( ) Upgrade( If'Abandon( ) - -arComplete System ❑ Individual Components
Location 7t (j
Owner's Name
Map/Parcel# �Q
Address ao 3
Lot#
Telephone# 2677 oZ` , _
Installer's Name
Designer's Name 5AS Z5
Address PO 43 6 X 5 1
Address P r
Telephone# ��
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided . gpd
Revision Date
Description of Soil(s)
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 to not to place the system in operation until a Certificate of Co npliance has been issued by the Board of Health.
Signed Date y
r
Inspections 0, t1 a�—
No.17—
�, FEE
C®M�''J ONWEALT14 Of MASSACHUSETTS
2--
T4
Board of Health, f MSI:
C EPITIFIdTt Of COMP [ IANCE
Description of Work: ❑ Individual Components)+Complete System "
The undersigned hereby,certi that the Sewage Disposal System; Constructed ( ); Repaired ( ), Upgraded k -'f, Abandoned ( )
by: P
at/ �S
has been installed ccordance with the roviysioms 10 CMR 15.00 (Title 5) and the a r ed design plans/as-built plans relating to
application No. d '�— , dated ! Approved Design Flow1 72 (gpd)
Installer `}�
Designer: C rInspector: X—I' L Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. --��4� v'" `"`'`Cf� F E E e7VI7
.
COMMONWEALT14 OF MASSACHUSETTS P/1 lie Z -
Board of Health, '
DISPOSAL S
XST ONSTR CTION PERMIT
Permission is hereby, granted to; Construct( ) Repair( ) Upgrade V'� Abandon( ) an individual sewage disposal system
at �' t/✓ .,rd; L ✓c'J !. �(p��L-/ as described in the application for
Disposal System Construction PermitNo. t=�' 1 , dated �cJ
W-6) S
Provided: Construction shall be completed within thL :yrs ofthe date of this permit. All local conditions
fmust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ~ r0°" Boar Of Health