HomeMy WebLinkAboutApp-Permit-Compliancen
No �- l6-o�si TM l vv�� � Ll LD 1 Fes. � �� 4 V 0 t �3 � FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, `iMQQM4MA.
AP LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon O - omplete System ❑ Individual Components
Location 0
Owner's Name
Map/Parcel# �
Address
Lot#
Telephone#
Installer's Name14—Designer's
Name
Address
Address Pe
Telephone#
Telephone# � _
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. required)`fl% gpd Calculated design flow Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
r
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further to not to place the system in operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed i Date
�i-'
rnspe=tions�' �bA �-
No.""flea-�t/ ! FEEIle
D.
COMMONWEALTH OF MASSACHUSETTS P"
Board of Health, `r� rzr�n;-,
CERTIFICATE Of COMPLIANCE
Description of Work:,,, ElIndividual"Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgr e&d' d ,_-Abando�ied l
by:
at %
has been installed i a�cco a e with the provist ns o 10 CM 5:00 (Title 5) an the proved design plans/as-built plans relating to
application No. % ��, dated ' /� Approved Design Flow'- (gpd)
Installer /�1411 If -1
Designer- ;nspector: / Datt:
The issuance of this permit shall not be cons ed as a: guarantee that the system will function as designed.
No.� r��" 1� � f� J� `. i�+! i�C PT- FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health,'VPrr,,m o urA , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) UpgradeAba don ( ) an individual sewage disposal system
at°
Disposal System Construction Permit No. /:� ? , dated 17
as described in the application for
Provided: Construction shall be completed within three years of the date of -this permit. All local conditions must be met.
Form 1255 Rev; 5196 A.M. Sulkin Co. Chadesiown, MA Date �! Board of ,Health
7It