HomeMy WebLinkAboutApp-Permit-ComplianceFEE E
r � � 7-COMMONWEALTH
Ao. � 1 1
USETTS
Board of Health,
R .4
APPLICATION FOR DISPOSAL YSTEI CONSTRUCTION PERMIT
l cation for Permit to Construct Repair(
PP O P O
U rade Abandon - ❑ Complete System [Q'I, ividual Components
Pg ( () P Y P
h cation
Owner's Name /v/t
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
UO
Designer's Name
Address
W
Address F, fC
, )v
Telephone#
p Q J
Telephone#
Z
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) 7 gpd Calculated design flow Design flow provided 4,1 /y' g gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s) jren!i
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR
M
l
-Itq / tv/ � /
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton t to ce s ��tjo,' operation until a Certificate o ompiiance has been issued by the Board of Health.
Signed /%" ' '' Date
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS
7- 141
Board of Health, yA3?t-M!J 01-1+ , MA. p� \
CERTIFICATE Of COMPLIANCE
Description of Work: U Individual Component(s) ❑ Complete System
The undersigned hereby certify that the S age D7eq7i
osal tem; Constructe O, Repaired ( ), Upgraded O, Abandoned ( )
by: /� _ , x, T
at IE2 ?Z J-a !I 94a
has been installed in acco dance with the rovisions of 310 CMR 15.00 (Title 5) and th a roved design plans/as-built plans relating to
application No. dated :;� % "% . Approved Design Flow °_ ,1 dd+
Installer ; `� /?.cam/ y s9 ! _�Y wk-lmw f 444��,
Designer: .)!: % '� R,-?,rInspector /1 J� .S���K s � Date:
The issuance of this permit shall not be/.trued as a guar tee that the system will function as designed.
-- No. 1i C -1-7 . q Q S FEE .
Board of Health, � t.o 01- rV MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade{ t/'Abandon ( ) an individual sewage disposal system
at
i
as described in the application for
Disposal System Construction Permit No. 17-14 dated _ .
Provided: Construction shall be completed within tu�Cs s of the date of this per /it All local cond` 'ons must. be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesbwn, MA Date � /` Hoard of Health `