HomeMy WebLinkAboutApp-Permit-ComplianceNo.
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ZBoard of Health, ��de�zsf5 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
INicationlfor a Permit to Construct( ) Repai�L pgrade ( ) Abandon( - ❑ Complete System C�tfc{ividual Components
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Owner's Nam4-1
Map/Parcel#
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,77 -a6
Address- Y
3d 4,7-
Lot#
Telephone# e
Installer's Name
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Designer's Name
Address
Address
Telephone# 'a
�, _ y
Telephone#
Type of BuildingLot 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 Design flow provided 57 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
rVolelo /
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 Lq place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed i Date
Inspections
No.—1?�"-��
COMMONWEALTH OF MASSACHUSETTS,
Board of Health,
CERTIFICATE OF COMPLIANCE /4,/
Description of Work: 9ndividual Component(s) : ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired 41,Upgraded ( ); Abandoned ( )
by:
at 14 CAPT. `,)i mr-o �
has been installed in accordant with the provisions of 31 CMR 15.00 (Title 5) and hea proved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
(gpd)
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Installer �• . - _. . s;
Designer: Inspector: L / Date: y
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �owDc-k) C -APE COD Se7 +tC 3VCS- FEE 06
COMMONWEALTH OF MASSACHUSETTS
Board of Health,.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at .-� S, i� .< % as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within dwei-- e2rs-of the date of this permit. All local conditioris must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date % % 7 Board of Health<