HomeMy WebLinkAboutApp-Permit-ComplianceNo. r FEE �
COMMONWEALTH Of MASSACHU ETTS
Board of Health, I MOUTH HPAI •I4DEPT.
APPLICATION FOR DISPOSAL i W�g�JIO,N .P EPMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon() - 0 Complete System ❑ Individual Components
Location s
Owner's Name
Map/Parcel#
Address
Lot# `
/ ��
Telephone# 46 Z
Installer's Name
Designer's Name
Address
Address
Telephone#
` —
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
- A/ .. , -047-. _P/i _ -_ / - ems'/
Lot Size sq. ft.
Garbage grinder( )
No. of persons 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 a es oft la th tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date G �b
Inspections
No. _ Z FEE- t�Z%i
Description of Work:
The undersh-med hei
b
at
COMMONWEALT14 01 MASSA 14USILI IS
Board of Health, MA.
,CERTIFICATE OF COMPLIANCE
❑ Individual Component(s) ❑ Complete System
>y certify that the Sewage Disposal System; Constructed ( ), Repaired/ ), Upgraded ( ), Abandoned ( )
has been installed in accordance with the P/Iovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 0 j 2_ dated i-- 7 e Approved Design Flow (gpd)
Installer
Designer: ---Inspector: t9`�„M Date:i
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �() _ % iC' �C%�"%��%CJ�C FEE
C®MHONWF-ALT14®F MASSAC14USETTS
Board of Health, i -% AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair) Upgrade( ) Abandon( ) an individual sewage disposal system
at f as described in the application for
Disposal System Construction Permit No. fJ ' <jf dated ` 7- J M
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 0 2 • Board of Health / -�`
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