HomeMy WebLinkAboutApp-Permit-ComplianceNo. ✓ FEE �� f
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ���\n®1.�����YlA• ��
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(,-,VU<P rade( ) Abandon( ) - ❑ Complete System LTIndividual Components
Location a
'A lsNA )4ce— q:� \,-) "e,,
Owner's Name (i"M iA Vv,, cS y 1 t
Map/Parcel#
Address a Q Q
Lot#
Telephone#
Installer's Name
Designer's Name
Address
3S M-A�v� S� �e
Address
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
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd-
Revision
pdRevision Date
Date of Evaluation
The undersigned agrees to ins above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o o c em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 9' / 7 ' O S'
Inspections
No.
COMMONWUALT14 Of MASSACHUSETTS �-rl 0
Board of Health, / A n wo t MA.
CERTIFICATE OF COMPLIANCE
Description of Work: tl Individual Component(s) ❑ Complete System
The undersi ped hereby certify that the Sewage Disposal System; Constructed ( ), Repaired graded ( ), Abandoned ( )
by: (10Nv\ 0 n
at aZ t -f %;� CZ 0C '- A `1-p_ -(kA A k."^0
has been installed in accordance with theprovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application Noo.+d� " —)2 � d , datef 7 69�. Approved Design Flow (gpd)
t
Installer Q. "C Com% _ rN j
Designer: Inspector:
The issuance of this permit shall not be construed as a guar.V. that
Date:
will function as designed.
-- - - —
COMMONWEALTH Of MASSACHUSETTS
Board of Health, V Pa vin o U�T�� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
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Permission is hereby granted to; Construct( ) Repair( rade( ) Abandon( ) an individual sewage disposal system
at ,�,'j (�,Q A C- e- A `1CZ> IPas described in the application for
Disposal System Construction Permit No. 05- -1 J? , dated ei - l 7-6S.
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Provided: Construction shall be completed withi.�, �� �of the date of this peranit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 4/ I Board of Health J