HomeMy WebLinkAboutApp-Permit-ComplianceNo. BWDc_17-37857��'=lam e/�
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Board oftrealth, �f��SDA__Ja_, MA.
Sri/s APPLICATION FOR DISPOSAL SYSTEM CONSTPUCTION P-:RMIT
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Application for a Permit to ConstntctO Repair( ) Upgrade(bandonO - B'Complete System Individual Components
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'Location
Owner'sNamc
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jMap/Pan cel#
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Address '7.r—G^,,9�✓
Lot#
Telephone#
Installer's Name
Designer's Name
Gfiy��
iAddress
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Address/CLr
�Telephonetk
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Telephone#
Type of Building
Dwelling -No, of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) gpd gpd Calculated design flow
Plan: Date.r' / %% Number of sheots
Title
Description OfSoil (s) _
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided S":I` gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t0 place the s/ysitem in operation until a Certificate of Complipce has been issued by the Board of Health.
Signed Date 2111117
Inspections
No FL1 �4 S= 60
/
COMMONWEALTH OF MASSACHUSETTS�—
Board of Health, LI421114r-1ILl9
CERTIFIrxTE OF rn PLIANCE W
Description of Work: E) Individual Component(s) DIdemplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(4, Abandoned ( )
at
has been installed in
application No. =i
Installer
with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated Y� �' ,,�,a Approved Design Flow r .gym-tV (gpd) ".
Designer: f ry ".<f" -Wit.:'` Inspector: "" 7� � . s` "ter`"( R , Date: 6 /eL
1-7
The issuance of this permit shall not be construed as a guaradt6e that the system will function as designed.
No t.'..i\.. 1..1 3�. ,i f'm., +� .s;.. a el t'"�[r'1 '1+':._(e..{mYEE
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COMMON WEALTH OF MASSACHUSETTS t tL III f 7,34
Board rfHealth, )dldog}r NIA.
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'DISPOSAL SYSTEM CONSTRUCTION P11RIMIT
Permission is herebygranted to; Construct(n) Repair( ) Upgrade(-)` Abandon( ) an individual sewage disposal system
at 1" f➢ ff `"7-A' I - ,I L,, 4, , S' A41f'& as` describedin the application for
Disposal System Construction Perr$it No. IL/- 7/ dated •'a ,'
Provided: Construction shall be completed within three - years of the date of this permit. All local, conditions must be met.
Form 1255 Rev. 5/96 A.M.Suft Co. Clierlde,MA,Da[e,,r'
Board of Health' '' 1
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