HomeMy WebLinkAboutApp-Permit-ComplianceNo. -� zow/O FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, Y8—{,MQ UM , MA. �((O® rl
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade andonO - ❑ Complete System10 ndividual Components
Location :;V C✓tR % J l t�
Owner's Name .<., ,,J
Q/ AJ
Map/Parcel#62
Address c' t lA
i& V %Vj'
Lot# W5
Telephone#
Installer's Name
Designer's Name
4 6��
Address
Address
Telephone#
Telephone# — 3—
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. `equr d) O gpd Calculated design flow Design flow provided_ gpd
Plan: Date Z Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No:
OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
F4
The undersigned a es install the ve described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of t lace s t in operation until a Certificate f Compliance has been issued by the Board of Health.
Signed a Date L
No. / COMMON LTH OF MASSACHUSETTS EEE
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: w(nndividual Component(s) ❑ Complete System vh
The undersigned hereby certify that Sewage Disposa�8ystem; Constructed ( ),Repaired (;o Upgraded ( ), Abandoned (
by:
at
has been `installed in accorda ce with the rovisions o 310 CMR 15.00 (Title 5) an t roved design plans/as-built plans relating to
application. No. -' dated '" Approved Design Flow (gpd) Af
Installer ro_
Designer: dv Gl i�L'l 4 44-0 Inspector: Date:
The issuance of this permit shall not be construed as a guarantee tha the system will function as designed.
No.--//---t�
COMM®NWEALTH OF MASSACHUSETTS
Board of Health, yA AM0 i M4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE•.
el
Permission is hereby granted to; Construct( ) Repair('' Upgrade( ) Abandon( ) an individual sewage disposal system
at e -PA n?d ..4,_(B Jge;Q IV-- as described in the application for
Disposal System Construction Permit No. dated,
Provided: Construction shall be completed withiAeM=
MIFof the date of this per it. All local condidons-4nust be met.
Form 1255 Rev: 5/96 A.M. Sulkin Co. Chadelown, MA Date !%�/lr� Board of Health /