HomeMy WebLinkAboutApp-Permit-Compliance'* No ('_L 1 A,41 Ca4le FEE /V' Of
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, 114 t? , ..,1 C .. _ , iA
APPLICATION FOR DISP ATi'W%W"9TRIUCTIO Y PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location ® e, C 1 0 L
Owner's Name
Q f3k
Map/Parcel# 55
Address 41
d A
Lot#
Telephone#
5- CC— ?9 -0 19 0 ->1 O
Installer's Name u� vh 1` 1
Designer's Name
E1-%
Address
Address
Telephone# 143o oZ -+
Telephone#
Type of Building �)0 �% i3 Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
gpd Calculated design flow
Number of sheets --
Name of Soil Evaluator
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
M&Ur,� Opp EAC- ?"- /4
ti P't 6&c> I--, Us4
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr7:apt=
in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 5 -cP7, ,% 7
Inspections
No. � � COMMONWEALT14 Of MASSACHUSETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
E
FEE
A?Je6a /e -
e�
Description of Work: A Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded), Abandoned( )
by: / "Q v
at a -1/D
has been installed inj�acco5rd�an e with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.(/f��T %�-d dat/edSL—_ Approved Design Flow (gpd)
Installer fi lw/ %l�AW _
Designer: 2!!�' 1�SGl�'! /4 // - Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Paal
COMMONWEALTH OF MASSAC14US ETTS
Board of Health,Vgtw,,/ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; /Construct(
at UV G `IlC! L,G 4z-1
FEE
Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. �l `� d dated
GIt"M S
Provided: Construction shall be completed within /mss of the date of this p it. A,11 local ccoon/di/tions %usstt be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �/ v / Board of Health / +l�