HomeMy WebLinkAboutApp-Permit-Compliance�7 `f� 1 �'� FEE ��• 0�
7—// COMMONWEALTH Of MASSACHUSETTS
Board of Health, A(iltlht�t , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairK)--Upgrade ( ) Abandon( ) ❑ Complete System ,Qlmdividual Components
Location36 P �� .� , ,.t�r•�,Q
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name 5' 0 �
Designer's Name
Address 3 6� .. �`� r
Address
Telephone#
Telephone#
Type of Building reS r d'e % / tk l Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided =gpd
Plan Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIO sec 44,.,t e,4 A -
1 ;�O A 54/
t
The undersign eJ s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree dt e t syste operation until a Certificate of Compliance has been issued by the Board of Health.
Signed y�`? i Date 1 - 1 3 - /-1
Inspections
COMMONW- AILT14®F MASSACHUSETTS
Board of Health, , MA. ef f
CERTIFICATE OF COMPLIANCE
Description of Work: -�vidual Component(s) ❑ Complete System
FEE
62.9
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired d, Upgraded ( ), Abandoned ( )
by:, �tG_,.s-+ < 1" ,5r -D4, c
at t;6 -u e -IP ✓.c l (44
has been installed in accordance with the provis.ons of„%10 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. '� dated /. Approved Design Flow (gpd)
Installer 5e-DIC.. C—of 611441 i -e-P I -I _ 14
Designer: ' " Inspector: C 1! hWn T?,fl
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. C— f' G ��� i FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ,]AaM,0011r MA.
DISPOSAL SYSTEM CONSTRUCTION HERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade ( ) Abandon( ) an individual sewage disposal system
at -aj Ce c -L / as described in the application for
%
Disposal System Construction Permit No. '--11
dated
Provided: Construction shall be completed within is oe date of this permit. All local conditions must be met.
C
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date 7 Board of Health °