HomeMy WebLinkAboutApp-Permit-ComplianceNo. �Z— . a y b��'l FEE
kPS
Board of Health, POA
, MA.
APPLICATION FOP, DISPOSAL SYSTEM STEM 'l ONSTR U'l IO PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade,(.�Abandon( ) - ❑ Complete System .2rIndividual Components
Location
Owner's Name
Map/Parcel#Address
Lot#
Telephone#
Installer's Name
c Designer's Name Q
Address
Address
Telephone# (-5A0Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided Wj gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned es to install the abo deed Individual Sewage Dispos System in accordance with the provisions of TITLE 5 and
further a r o to pl on until a Certificate of Co pli a has been issued by the Board of Health.
Sign Date
Inspections
No. COMMONWEALTH OF MASSAC14USETTS FEE
Board of Health, MA.
CERTIFICAT Of COMPLIANCE
Description of Work: 9461vidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed Y" Repaired ( ), Upgraded ( ), Abando4ed ( )
by: �/j4i ,9 cam. �. r 57-- --r-ifi Z
at ; �Z TJ/l i I- L �, , �Z C G A.,e
has been installed in accordance with therovisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
.
application No. 2 0, dated ` lio.,Approved Design Flow (gpd)
Installer .✓, .l'.?
Designer: Inspector: Date:. ��-
The issuance of this permit shall not be construed as a guarantee that tZ system will function as designed.
No. FEE 7
Board of Health, MA. ®�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (/j -'Abandon( ) an individual sewage disposal system
at -Z Z zZ ,[I % /) G /I`ll' as described in the application for
Disposal System Construction Permit No. �, dated��
Provided: Construction shall be completed within thx-4dar of the date of this t)ermi t. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date (9 _. !� U�-Board of Health G