HomeMy WebLinkAboutApp-Permit-ComplianceNo.
FEE
COMMONWEALTH\ SOF MASSAC14USETTS
Board of Health, Y1.�9i% 6 VW , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairg Upgrade( ) Abandon( ) - ❑ Complete System Xindividual Components
Location
Owner's Name
p r,
10-Ak
Map/Parcel# G�
Address
L,
Lot# C
Telephone#
`
4e
Installer's Name
�/ f Designer's Name
Q
Address 7 104ir&
RIL Address
Telephone# _or776
Telephone# :Qll,
Type of Building (/
Dwelling - No. of Bedrooms
Other -Type of Building
Other Fixtures
Design Flow (min. required)
Plait: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
OF
ZZ
gpd Calculated design flow
Number of sheets
ALTERATIONS
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder( )
Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
l -.r "e --e
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 a in opera on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ' /.g V t'�O ��k
? 7
Inspections` I b �G f'1�t� �O►�""` TW,le-td L� boc.s_✓A c c�, U����ivlve7l`/
-7-',2-/-)6, Vec•_tiee_,I ee-- 01-C
No. �' W
FEE
COMMONWEALTH OF MASSACHUSETTS U--1:
Board of Health, Yam e)I mf
CERTIFICATE Of COMPLIANCE A
Description of Work: Individual Component(s) Ll Complete System
The undersigned here y certify that the Sewage Disposal System; Constructed ( ),Repaired ( Upgraded ( ),Abandoned ( )
at Gt �� _ f 4�1�,rl e►9
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
application No _1 - dared `�--5 ` Approved Design Flow """' (gpd)
Installer (i4 1 t J
Designer:� (.� .• Inspector: Date: —7— D /
The issuance of thispermit shall not be construed as a guarantee that the system will function as designed.
No,f�-
Permission is hereby
at
relating to
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V�0it'- MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
ted to; Construct( ') Repair y) Upgrade ( ) Abandon ( ) an individual sewage disposal system
*d
t�1.
Disposal System Construction Permit No. Ko -1 "dated77-
as described in the application for
Provided. Construction shall be completed within three years of the date of this e�All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Cha iegown, MR ' • Date Board of Health
_;,