HomeMy WebLinkAboutApp-Permit-Compliance-+ No. _ /4 ` FEE
COMMONWEALTH OF MASSACHUSETTS
SETTS
Board of Health, f' Q VCU , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System udividual Components
Location
Owner's Name ci-
Map/Parcel#
A410&
Address ILI k Ve,,,, Lw
Lot#
Telephone# 16 336 79
Installer's Name
�/� Lc, A ce-, -c h
Designer's Name Al
Address G
, �/G�
Address
Telephone#
7 L _ 07(,- G M
Telephone#
Type of Building '��,lrK� Lot Size /9 4119,53 _ sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Y3 Design flow provided 3S gpd
Plan: Date�i - Number of sheets Revision Date
Title
Description of Soils) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
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 oICInpl7nce has been issued by the Board of Health.
Signed Date aA %
Inspections
No. ! FEECOMMONWEALTH OF MASSAC14USETTS
---
Board of Health,y-�R--M6 I Tru , MA.
CERTIFICATE Of COMPLIANCE � I � Vt
Description of Work:,Aln-lvidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ),, Abandoned ( )
by: K J�4,- f, -,J Oe A'u�-Ar.�q
atpli �4� L r.A(Q - has been installed in accordance with the pr visi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. i dated G Approved Design Flow (gpd)
Installer _ ..
Designer: Inspector: _ _Date:
The issuance of t permit sbali•not be construed as a guar/e, that the system will function as designed.
No. FEE ^_
COMMONWEALTH OF MASSACHUSETTS r
, yr r m w
Board of Health, ,fin t MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( *.-<epair( • ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at e
L
Disposal System Construction Permit No. ' , dated I [.
as described in the application for
Provided: Construction shall be completed wi hint ree years of the date of this er(om�/,�iitt. All local conditions must be met.
r 4
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date I Board of Health I