HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE JV O 40
PFAAW COMM®NWEALTH Of MASSAC14USETTS
Board of Health, /'"/-/�%/%�6% %� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (/Abandon( - &Complete System Q Individual Components
LocationOwner's
Name
%S
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name G�
Designer's Name
Address - ✓c r
Address
Ala/ vc "
Telephone# 7
Telephone#
Z
Type of Building {/�j�C Lot Size �? 7 O'� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder,('
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min.
Plan: Date
Title , S c5
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow ^ vl Design flow provided 3CIF_ gpd
Number of sheets f Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of to nlace th tem in operation until a Certificate of Co%�plian a has been issued by the Board of Health.
Signed Date l /,j
Inspections
FEE 7v
No. �pp��l
COMMONWEALTH ®F MASS CHUS�ETTS2. i
Board of Health, ?'�/r � y` MA. /'
CERTIFICATE Of C, OMP][ IANCE /5--��--
Description of Work: ❑ Individual Component(s) O Complete System
The undersigned hereby cert that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (+'Abandoned ( )
by: f% /!f t�i
at SL
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. 0 -3/ dated `'%7 ® Approved Design Flow (gpd)
Installer U� L
Designer: Inspector: Date:
The issuance of this permit: shall not be construed as a guar e�thte, will function as designed. -
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, !it' %/moi% ; MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran d to; Construct( ) Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system
at j 9-� fl/J as described in the application for
Disposal System Construction Permit No. •1-1�= dated % 42-3.
G �S
Provided: Construction shall be completed within dTPtV=M= of the date of this permit. All local copditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /+� l D:3Board of Health
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