HomeMy WebLinkAboutApp-Permit-ComplianceNo. I.1 -10S - FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, &MO 0TV , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( - ❑ Complete System XIndividual Components
Location 15
H4 Y&O0 6-
Owner's Name KGJS Sem
Map/Parcel#
T
Address
Lot#
Telephone#
Installer's Name
pE� `off
Designer's Name !a
Address
Address
Telephone#
SO S _ Lf `Z `� ..
Telephone#
Type of Building Rlus woyri /-r— 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)
Plan: Date
Title
Description ofSoil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &1-06 pp -044< t+00s e, To -AILJ I-.
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n t place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed � �� / t Date 5 —13 na V 1
No. I5 ` �.. ,J�r/, r� FEE
x, COMMONWEALTH OF MASSACHUSETT 6,.- �a �
Board of Health, �(4 l W
CERTIFICATE OF COMPLIANCE C) 1/\
Description of Work: l Individual Component(s) ❑ Complete System f
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (r, Upgraded ( ), Abandoned ( )
by: (2,4 P& Ic > t r3 ei�C�7iGYET A -t . s &S L,(.,(Zl
at 1.5 14ok0i Gal? k ui5
has been installed in accordance with the pro 'sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated �G Approved Design Flow (gpd)
Installer. �^
Designer: �Yi-GT- Inspector: Date:
The issuance of this permit shall not be construed as a gu tee that the system will function as designed.
No, U FEE _
COMMONWEALTH 4LTH ®E M ASSAC14USETTS &P
Board of Health, MA. £'
RMIT
DISPOSAL SYSTEM CONSTRUCTION PER
Permission is hereby granted to; Construct( ) Repair (X) Upgrade ( ) Abandon ( ) an individual sewage disposal systeidn
/ ,
at
Disposal System Construction Permit No. S dated �.
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, 5/96 A.M. Sulkin Co. Chadeslown, MA Date (,3 Board of Health �-`.�