HomeMy WebLinkAboutApp-Permit-ComplianceNo. 9600-41-4aSZ ' / �/ FEE t6 ( 00
17-146 COMMONWF-ALT14 OF MASSAC14USETTS C&P ct (0
Board of Health, /�" e3p de 7e , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (!l--Ulpgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location �� ,.��ellOwner's
Name
Map/Parcel# 403 7.5 Q
Address
Lot#
Telephone#
Installer's Name �a Ca
6 � � Ci�J%C GSL
Designer's Name
Address
tv
Address
Telephone#3 a,�_ 77s�_ z8z y
Telephone#
Type of Building ..-* `lr.- 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 Soil (s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided gpd
Revision Date
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 not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ;ems Datedl T
Inspections� —1
No.�T C i Z , FEE
Board' of Health, r`� f� MA.
CERTIFICATE OF COMPLIANCE
Descrin of Work: "In vidual Component(s)❑ Com lete System
��
p� P 3's
The undersigned hereby certify that th ewage Disposal System; Constructed ( ), Repaired(�'}, Upgraded ( ), Abandoned ( )
by: / Q<rl �,�O��e� �G �c✓� Sc"s�sG v -acre -^S
at
has been installed in accord ce with the rovisi ns of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ! dated % Approved Design Flow ��""' (gpd)
f
Installer kl), Vk4txr� f�i AL r :
Designer: �''Inspector: Date:
The issuance of this permit shall not be construed as a guaran�e�at the system will function as designed.
No. a f-7-�(8Z- C�"P� " ��S ' FEE J
'L..®MMO WFALT14 Of MASSAC14tJSETTS
Board of Health, 7` MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) RepairUpgrade( } Abandon( ) an individual sewage disposal system
atFel as described in the application for
-IV
Disposal System Construction Permit No. /7—//' , dated — 117
Provided: Construction shall be completed within three years of the date of this permiti. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat % Board of Health