HomeMy WebLinkAboutApp-Permit-ComplianceNo.�- "'_ _ w . FEE
COMMONWE4�'W, V ��� �-*uo��
Board of Health 1146 ROUTE 28 ALL T/q 1,4 /s
YARM uTH SAA
APPLICATION FOR DISPOSAL SYS COMT TION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade j Abandon( - ff Complete System ❑ Individual Components
Location �'
Owner's Name
Map/Parcel# 3
Address
Lot# t
Telephone#
Installer's Name `
Designer's Name
Address
Address
Telephone# „ a .49QR
Telephone#
Type of Building S&�) VA, Lot Size � _ sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min.required) �b gpd Calculated design flow 33 a Design flow provided .�S gpd
Plan: Date %6 O 4 Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION
,,OFREPAIRS ORALTERATIONS �,%,Cn�•
la - 5,) a xa
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 system in operation until a Certificate of Compl' nce has been issued by the Board of Health.
Signed Date
4
Inspections
No. GQ( ,ZU 6 FEE YF
COMMONWEALTH OWMASSACHUSETTS (40
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) W Complete System -
The undersigned hereby certify that the Sewage Disposal System; Construcj d J( 3)' Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at �j j OI�NS
has been installed in accordance with the provisions of 310 CMR 15.00 (Title `4 ahat't e approved design plans/as-built plans relating to
application No.nC)j(ated 1p�p'- Approved Design Flow pd)
Installer (� ,�Pr( is !° r� /V1
s
Designer: 1 t t t Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Nopc! - a°D C
COMMONWEALTH Of MASSACHUSETTS
Board of Heealth, I A WA4—ni�-,
T , MA.
DISPOSAL STST CONSTRUCTIONPERMIT
/v
FEE
C. LI a qZ7
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (� Abandon( ) an individual sewage disposal system
at
as described in the application for
I
Disposal System Construction Permit No)Q-t-,4�C , dated / o C G
Provided: Construction shall be completed within tlwe�pcars of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health