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HomeMy WebLinkAboutApp-Permit-ComplianceNo. SDC—� / FEE , ©a COMMONWEALT14 Of MASSACHUSETTS Ck"q,3,,, `Board of Health, 4,i-lvk�l-, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - of Complete System 0 Individual Components Location /,3 r ®�ff//f �w Owner's Name Map/Parcel# Address' Lot#. 3 Telephone# Installer's Name G,�P tj Designer's Name Address I � ! Address , Telephone# V b I Telephone# S -v q 5 x�v� Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. required) gpd Calculated design flow Plan: Date /-9 % Number of sheets % Title Description of Soil(s) _ Soil Evaluator Form No. Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided pd Revision Date DESCRIPTION OF REPAIRS OR ALTERATIONS -2 ?, 4. J 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 Compliance has been issued by the Board of Health. Signed Date /d " /- l� Inspections - ®�'INI®N ITIT Of MASSACHUSETTS fas of � - Board o Health, ` 0 , MA. i3t.�P 1�-bo►9�� IorMMO f S CERTIFIC TE OF COMPLIANCE � A o� %o/t��lb Description of Work: 0 Individual Component(s) Complete System The undersigned hereby certify that the Sewa a Disposal Syst m; Constructed ( ), Repaired ( ), Upgradea, , , Abandoned ( ) f by: .s e° 1 r .3/� !' ,O�: at Z-457- a +C%`. has been installed in accord n ith the provision of 31-0 CMR 15.00 (Title 5) and thep 'o d design plans/as-built plans relating to application No. % dated 46 ' lj( Approved Design Flow x�' a d) Installer & /A Designer: o;tA �;ii;lCE�'r Inspector: Date: Wd The iccuance of this nermit shall not be construed as a guarantee that thetem ;i function as designed.