HomeMy WebLinkAboutApp-Permit-ComplianceNo. • t v - -33 Re c dc FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ) Q -g , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Namejd�nj=L-L C
Map/Parcel#
Address
Lot# '
Telephone#
Installer's Name ` 1
Designer's Name.
Address )I q U
Address
Telephone#
Telephone#
Type of Building 1=pTrY1l1�►� P/�j 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
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
i
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 thea
in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed � � Date V
0
Inspections
,No16 .
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y49MO WA , MA.
CERTIFICATE OF COMPLIANCE
s
FEE
&c07 -e_
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( )
at '� Ks l_i .P 0 1010 1 QV M
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.. —3!, dated -/L . Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE t'
COMM®NYvTALTH OF MASSACHUSETTS
Board c f Health, Ya mnt n!* , MA.
DISPOSAL SYSTEM CONSTRUCTION P ERMI1
Permission is hereby granted to; Construct( ) Repair(/) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at gi 6AL)DI Isid / as described in the application for
Disposal System Construction Permit No.dated-_�
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. ChMesiown, MA Date Z -Y-145, Board of Health