HomeMy WebLinkAboutApp-Permit-ComplianceNo. �S/1/ l l1�L FE
COMMONWEALTH OF MASSAC E
Board of Health, YAAW MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ®"Complete System ❑ Individual Components
Location Z
S /
Owner's Name ` L"
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
ly'l e 130 j
Designer's Name a ( r cA4 e,
Address
a
Address
Telephone#
�U (,� d
Telephone# f a �' ��'
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building —
_ Lot Size
No. of persons
sq. ft.
Garbage grinder( }
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) .3-30 gpd Calculated design flow Design flow provided iTSy gpd
Plan: Date 2— 7-/,/- Number of sheets Revision Date
Title n
Description of Soil (s) fee fly �i /
Soil Evaluator Form No. 41 Name of Soil Evaluator ` ar(el ... �P. f Date of Evaluation O ' 7
DESCRIPTION OF REPAIRS OR ALT
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 lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �
Si � � � -Date
Inspections
,i
No. fiT
0 COMMONWEALTH OF
Board of Health, A- fil o dTw MA `vL as /01t7
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) iU ( inplete System
The undersigned hereby cer ' !hat the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 'C 1
at Z 3
has been installed in accordance with the p/ ovisi - s of 310 CMR 15.00 (Title 5) and the approved design plans/astbuilt plans relating to
application No. 17—L3 , dated Approved Design Flow (gpd) 1
Installer
Designer: 4 4 f Inspector: Date: '"
The issuance of this permit shall $ot be construed as a guarapfte that the system will''function as designed.
FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, V d ( JVJ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) R7air ( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ..l, ) J+l�P`r �® as described in the application for
Disposal System Construction Permit No. _, dated , r�
Provided: Construction shall be completed within,thEe erars of the date of this ern-ir All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown,MA Date Board of Health