HomeMy WebLinkAboutApp-Permit-ComplianceNo. %7— J "a� / `y5 '` FEE
COMMONWEALTH OF MASSACHUSETTS C*;& -m55 -
Board of Health, � � , , /-I , MA.
APPLICATION FOP DISPOSAL SYSTEM STEM CONSTRUCTIO1V PERMIT
Application for a Permit to Construct( ) Repair (44upgrade ( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location �7 ��aC �,
Owner's Name erlG/-r �%G/rlO�2
Map/Parcel# ��'
Address
Lot#
Telephone#
Installer's Name CSS aGCo �rik�
Designer's Name
Address
Address
Telephone#�� ate_ ?7� ��� f--
Telephone#
r �
Type of Building 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 of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
--C ,
Name of Soil Evaluator
r.
Design flow provided
Revision Date
Date of Evaluation
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 not to place the
essys � ,>nneration until a Certificate of Compliance has been issued by the Board of Health.
Signed „�'` '/"' - `- Date
Inspections
No. EE O
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA. �!!
CERTIFICATE OF
N
Description of Work: a Individual Component(s) ❑ Complete System
The undersigne ereby certify that the S age Disposal System; Constructed ( ), Repaired f'<Upgraded { ), Abandoned O
by:</
at
has been installed in accord ce with the provisions of 310 CMR 15.00 (Title 5) an e proved design plans/as-built plans relating to
application No. dated/7. Approved Design Flow (gpd)
Installer eA-0 t. ♦`°I tui ha
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gu tee that the system will function as designed.
No. Y / Jf /� 7— / �a ? � FEE YS S 5" t
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(C-1-/1Jpgrade( ) Abandon( ) an individual sewage disposal system
at /, ";, /'1G c' %7ic^ / ��� as described in the aDDlication for
Disposal System Construction Permit No. I -7-1111 dated
Provided: Construction shall be completed withhii/n three years of the date of this permit. �ll�local condi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date - Y ?Board of Health (��/