HomeMy WebLinkAboutApp-Permit-ComplianceNo 8ab}9c-t?-w8'lb �,�'/�l�lll0 ,Z ,�"�X3'/
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WZBoard of Health, hg .mss vla,f4 MA. 16?Z
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(llUpgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
Owner's Named / c
Map/Parcel# 3 3/y�7/
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address ��—,
Address
Telephone# tSG�� yTj- _ 2,,-Z j--
Telephone# 5V T T S3/ 3
Type of Building os �u�i/el- Lot Size 7-0,2 sq. ft.
Dwelling - No. of Bedrooms - Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 7 2 4V gpd Calculated design flow Design flow provided "7'2' gpd
Plan: Date /T Number of sheets :7 Revision Date
Title/�v-sJ�iz�� s�d�i�iC� fs�scco� u/���� Z �,4!5z
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n� ac the In8ratiren til a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections 7�/r
No. COMMONWEALTH ®F MASSACHUSETTSa A- F
l
Board of Health, MA. &wl i
CERTIFICATE OF COMPLIANCE oA -7—/37-7
Description of Work: ❑ Individual Component(s) A Complete System
The undersigned hereby certify that -the Sewa Disposal System; Constructed (' ), Repaired(Upgraded ( ); Abandoned ( )
by: /`viii` 0 ifPG/if�9 4!51�.
at .�
has been installed 'n a
application No
Installer
with the rovis>ons of 310 CMR 15.00 (Title 5)
Plated '� , I `.Approved Design Flo
z -
Designer: Inspector:.,
.fes
design plans/as-built plans relating to
Date: 6 —!
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE• W
G" (� (0 e)
Permission is hereby granted to; Construct( ) Repair(( Upgrade( ) Abandon( ) an individual sewage disposal system
at .72 s' _ z - as described in the application for
Disposal System Construction Permit No./ 7 % c� dated
Provided: Construction shall be completed within ears of the date of this per/,Mi All local condidons must be met.
/Form 1255 Rev. 5/96 A.M. Sulkin Co. os� MA j Date / Board o� Health i
(d l o �`�' '�( � ver f'� J /� At;l lowe�