HomeMy WebLinkAboutApp-Permit-ComplianceFEE Z'S
COMMONWEALTH OF MASSACHUSETTS Ci.4007Zb �
Board of Health, �, AV{WOM MA.
APPLICATION FOR. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair (VUpgrade ( ) Abandon( ) - ❑ Complete System ndividual Components
Location
Owner's Name
L '
Map/Parcel#
Address Ll5
t W i
Lot#
Telephone#'�
9!,
Installer's Name Re i
Designer's Name
Address2q6r(%-tXJe6-fem 9&
Address
Telephone# . `j'o
Telephone#
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
Plan: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
Name of Soil Evaluator
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 agrees to rMt to lacthe system in operation until Certificate of Compliance has been issued by the Board of Health.
Signed 1JI&A Otic— 10.X✓1. Date�V--ZE ,
Inspections
No. EE
COMMONWEALTH OFACHUS TTS 1
Board of Health, _la2MOt Ml MA. dv
CERTIFICATE Of COMPLIANCE e% ,, d
Description of Work: kfindividual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V1, Upgraded ( ), Abandoned
by: KPI O.P. C -T- ;,b 1 V V FCQ I-- 11 c
at 4�,Rrt-rNU
has been installed iffi~'c a cel -tYfer vi ns of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. fh — 40 dated_' Approved Design Flow (gpd)
Installer T , C •i4STh U
Designer: Inspector: /� Date:
The issuance of this permit shall not be construed as a guar dethat the system will function as designed.
No,-b�„—`�'=10-105(01 K, V' O�I �i�• t�C FEE `
COMMONWEALTH OF MASS C14USETTS c i- 4� cowl -51
Board of Health, l`� R•-fLIV1T, n U't t J MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is herebygrantedto; Construct( ) Repair() Upgrade( ) Abandon( ) an individual sewage disposal system
at qs `�.�Cmm 30 1 t31 La, , as described in the application for
Disposal System Construction Permit No. 4, dated'
Provided: Construction shall be completed wtthin� is�� he date of this permit. All local condi ' s must be met.
Form 1255 Rev.. 5/96 A.M. Sulkin Go. Chadegown, tin Date