HomeMy WebLinkAboutApp-Permit-Compliance~ No. '�r� �!/� / FEE
COMMONWFALT14 Of MASSACHUSETTS
Ppb,-^l,'TH YEALT EFT.
1146 HOU I 1= Zk5 Board of Health,,
APPLICATION FOR DISP®S LSSWUO-914ST TION PERMIT
Application for a Permit to Construct( ) Repai�pgrade( ) Abandon( ) - ❑ Complete System Andividual Components
Location ,/;/GOzf.r' G'
Owner's Name
Map/Parcel# 2—,�V
Address v ��
Lot#
Telephone# zp
Installer's Name,*
Designer's Name
Address 61'3
Address
Telephone# ',� �do� �7j��
Telephone#
Type of Building A0 n 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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation
.
4.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of two placethesystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. ��— �d-� COMIM ONWEALTH OF MASSACHUSETTS FEE
Board of Health, ; MA.
CERTIFICATE Of COMPLIANCE 1
Description of Work: vidual Component(s) ❑ Complete SystemY
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 22,�lU/�.7'il L
at ,�✓��` ...j'
has been installed in•accorda ce with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / ,dated - Z?'`— Approved Design Flow _(gpd)
Installer .? %
Designer: " Inspector:
The issuance of this permit shall not be construed as a guara
c.
No. - e�-
Date: _ — 2tV _
that the system will function as designed.
COMMONWEALTH LTH ®F MASSACHUSETTS
Board of Health, , MA.
➢FISP®SAI. SYSTEM CONSTRUCTION PERMIT
FEE s!J V
Permission is hereby granted to; Construct( ) Repair(--�'" Upgrade( ) Abandon (A" individual sewage disposal system
at -// as described in the application for
Disposal System Construction Permit No. � Z,dated
Provided: Construction shall be completed within three years of the date of this per . l local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ^ 1� ' Aoard of Health
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