Loading...
HomeMy WebLinkAboutApp-Permit-Compliance_ YAROU HEALTH DEPT. No. ® &4 -� % 1148 ROUTE 28 FEE C®MM®P A TA4C14 SETTS 3 Board of Healt7SAL MA. APPLICATION FOR DISCSYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() ❑ Complete System ❑ Individual Compq;ients 11 Location Owner's Name�- Map/Parcel# % g /� � Address Lot# - , �` Telephone# Installer's Name � Designer's Name Address t s Address Telephone# ©� Telephone# _. Type of Building /&4 Lot Size C;u sq. ft. Dwelling - No. of Bedrooms 1-3 Garbage grinder Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided3�l gpd Plan: Date- ' jf`'� Number of sheets Z Revision Dam Title Description of Soil(s) Soil Evaluator Form No. Name of Soil E luator - ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furl}er agrees to nom+ lac the system in a duntil a Certificate of Compliance has been issued by the Board of Health. Signed �/ �'�--Date Inspections No. FEE COMMONWEALTH OF MASSAC14USETTS Board of Health, , MA. CERTIFIG& Of COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned at has been installed in accordance with the provisions of 310 CMR I& (Title 5) and thea proved design plans/as-built plans relating to application No. o� ~! dated -6- .Approved Design Flow (gpd) Installer Designer: SCJ d✓��� "-""" Inspector: Date:yCJ The issuance of this permit shall not be construed as a guarantee th t de system willfunction as designed. No. 4) � - ( 3 FEE Pe at Board of Health, DISPOSAL SYSTEM CONSTRUCTION PERMIT Disposal System UpgN ..�. � ,) an individual sewage disposal system 7'1V x/121" 41' 1W as described in the lication for Permit No. `i1� - / dated Provided: Construction shall be completed within three years of the date of this mit. All local conditions Wst be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �(D 0(� Board of Health