HomeMy WebLinkAboutApp-Permit-ComplianceNo. 7 2—, FEE V
f % e� COMM ON % &i4 TTS � "��9�
�S Board of Health,1146 ROUTE 28 MA.
APPLICATION FOP, DISP®f ATT?Y '�WNMfRUCTI®N PERMIT ��
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location
�� Owner's Name
Map/Parcel#
Address
Lot#
Telephone#3
Installer's Name
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
'30Design Flow (min. required) gp73"d Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) „�f a..Z"- (rltit�
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 agre to not to place the system in operatio til a Certificate of Compliance has been issued by the Board of Health.
Signed A Date 4
rinspections &:2 S -� 7 C_ f� ��✓! 1Y%T9/J'� !�''% %/ C '�(_ 41�L� `G
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No.
0v COMMONWEALTH Of MASSACHUSETTS
te'rP3�i�"/
Board of Health, MA.
C EPTIFIC�E Of COMPLIANCE
Description of Work: ❑ Individual Component(s) �Momplete System
The unde'rsigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,);Abandoned ( )
)
by: (9
at
has been installed in accordance with the ro 'sions of 0 CMR 15.00 (Ti and the proved design plans/as-built plans relating to
application No. 6 % 42—, dated - Approved Design Flow �(gPd)
Installer
Designer: - ��z�.0 `�.�1 ��.. Inspector: ". Date:
The issuance of this permit shall not be coiLstrued as a guarantee that the system will function as designed. -
rte`aJ FEE �7 CIU
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COMMONWEALTH OF MASSAC14USETTS -39�
Board of Health, : , MA.
DISPOSAL SYSTaCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(
at
Upgrade( -r Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. (::7 7' fQ , dated ..6
WVs .
Provided: Construction shall be completed within -ee pears of the date of this permit. All local conditions must be met.
Form 125/5 Rev. 5//96 A.M. Sulkin Coo../Bosto MA / Date 6 0 / Board of Health
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