HomeMy WebLinkAboutApp-Permit-ComplianceNo. b04�-D 0-COL12, �& / "" FEE . D O
�.l 6635
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7-1 Sl COMMONW �.T14 Of MASSAC14 SETTS �
Board of Health, �yjww MCII%7" , 1VIA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade O Abandon O LLI Complete System 0 Individual Components
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Location
Owner's Name
Lev
Map/Parcel#
Q 78 i +
Address
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Lot#
Telephone#
Installer's Name
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Designer's Name.
Address l e
v
r, Address
Telephone#
'L
Telephone#
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
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Design Flow (min. required) 3 J gpd Calculated design flow Design flow provided 3 3 S gpd
Plan: Date 9-/ Z -/ % Number of sheets J Revision Date
Title
Description ofSoil (s) e0/d14
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Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF
1` .
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 PI ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed A; 4 t r Date / 3`
Inspections -7 bio -7 T Ve i V eaJ 0,,d [4-y u 5-1e—
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COMMONWEALTH OF MASSACVUS
Board 'of Health, , `)KA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) t11.1Complete System
The undersigned hereby certify that the Sewage Disposal System;nstructed (L) Repaired ( ), Upgraded ( ), Abandoned
by j
atZ 016,
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans° relating to
application No. r dated. I Approved Design Flow`��� r'� . (gpd
r
Installer
Designer:�r. �a2�if/Q. G: Inspector: Date:'' / 7�
The -issuance of this permit shall not be construed. as a guarante rat the system will function as designed.
No.C�0 i o FEE -= -
COMMONWEALTH Of, MASSACHUSETTS
Board of Healthy Y&gJLA LM - MA ✓
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby grant6 d to, Construct( R�pair (pgrade ( ) AbZdon ( ) an rAvidual sewage disposal system `
h
at. 1 '`' >✓ as described in the application for
Disposal Sys�teri Constructton Permit No `--�"� , dated ,' ", - L�
Provided: Construction: shall be completed within tlx4e_y,ears of the ate of d2lis per All local con itions must be met.
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Form 1255 Rev. 5/96A.M.A..M. Sulkin Co. Chadeslown, MA Date �` 8-7 (7 B"onar3 of I Iealth
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