HomeMy WebLinkAboutApp-Permit-ComplianceNo. di V17 J�W KJ ��19t FEEYW
COMMONWEALTH OF MASSACH US TT�
Board of Health, IAr{LMA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(,,/Repair( ) Upgrade( ) Abandon( ) - a)complete System ❑ Individual Components
Locationa 1z r f
Owner's Name Ito
Map/Parcel# Q I
Address
Lot#
Telephone#
Installer's Name 1 �f
Designer's Name
Address 7 ! q
Address
Telephone# L.136. s a a<� — q j
Telephone# 7 ,5.. %V%
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) G gpd Calculated design flow
Plan: Date 7 Number of sheets i
Title
Description ofSoil (s) r3+
Soil Evaluator Form No. Name of Soil Evaluator 1,e-1
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
tion 6- 4 7 — / /
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 J7
Inspections
No. �� ) (" i — 00 1 b
FEE T r. 0V
COMMONWEALTH OF MASSACHUSETTS
Board of Health, VA-&MOi304
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ®'Complete System
The undersigned hereby certif that the Sew•age)Disposal Syst Constructed ( ), Repaired (. ); Upgrade ", Abandoned
// ��
�D r te ��
( )
by: . ll ','
,�✓ f -m,,4,-
at
at � � �
has been installed in accordance with the provisiorfs of 310 CMR 15.00 (Title 5) and thhe approved design plans/as-built plans relating to
application No. dated "" ^' Approved Design Flow -� (Rd)....
Installer P
>
Designer: i 1 Inspector: Date:
r
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. 6C)" (0�� t !
FEE
COMMONWEALTH Of MASSACHUSETTS
C,6�* G (o Ao
Board of Health, �YAef V%Qt�(j , MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ). Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at t 100-) as described in
the application for
o
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within 4b//e ate of this per it. All local condi 'ons
must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co.PWeslown, MA` t Date7— ;r/ oard of Health