HomeMy WebLinkAboutApp-Permit-Compliance/6 COMMONWEALTH OF MASSACHUSETTS ice`
r Board of Health, YA-(LMO VIV MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication for a Permit to Construct( ) Repaii:x pgrade( ) Abandon( ) - ❑ Complete System ..a dividual Components
.ocauon
Owner's Name S d
Map/Parcel# 'do 'pn
Address
Lot#
Telephone#
Installer's Name
7n Dsigner's Name
Address
ddress
Telephone#
1 Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _,
Lot Size sq. ft.
Garbage grinder ( }
No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design flow Design flow provided �_ gPd
Number of sheets
Plait: Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further aMs not to lace the system in operation until a Certificate of C mpliane has been issued by the Board of Health.
Signed Date
Inspections
_ r
No. /(! p +F" r%r'�dl/rrEc v u r+
16 �r CO�1[MONWFALT14 ®F MASSACH TTS � 741
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE,
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (t, Upgraded ( ), Abandoned ( }
41
has been installed in acco/rAati'e're with the rovisions of 10 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No.?f :� ! c dated{ . (Approved Design Flow _��(gpd)
Installer i GP1�?_Q�� �i1 X2 °a"�_ m•-i�% C5)_�_i"Z)
Designer: Inspector: " 9r:.e Date: _
The issuance of this permit shall not be construed as a gaaran thathhe system will function as designed.
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No. AV tou
///,!� FEE
r l COMMONWEALTH OF MASSACHUSETTS ,'�'
Board of Health, _ VA eMa MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at fs
"72 ✓s3 .e . -1 .z C -e
Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit Noq% --J- (ex 0—dated
Provided: Construction shall be completed within tk.re,.a--�ears-of the date
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date 50- //4 Board of Health