HomeMy WebLinkAboutApp-Permit-ComplianceNo.✓ FEE ✓V '
` ,6RMOUTH HEALTH DEPT.
Board of Health, 1145 KOUTE 28 ,MA
APPLICATION
N' FOR DISP I:' pW9 T CTIO1�Y�T
PERMIT
Application for a Per to Construct( ) Repair( ) Upgradek<Abandon( ) - Z'Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
llit4/
Address
r
Lot#
Telephone#
Installer's Name
G Designer's Name
Address
`
—� Address
X �I
Telephone#
Telephone#
Type of Building Lot Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures aa
Design Flow (min. required) gpd Calculated design flow Z!X6 Design flow provided 9�e gpd
Plan: Date Y 2�S"=a6 Number of sheets z Revision Date
Title
Description of Soil(s) _S
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1.
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur not to place the system ' operation until a Certificate of ompliance has been issued by the Board of Health.
Si ned Date 7�
Inspections
No.
060- /_3 FEE
' (J( 1
Board of Health,
�%f1�10�/`i�i MA:'
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) P<Omplete System ",
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),Upgraded Abandoned( )
by: AVAI R 6k !4 77A e 0 .
at l �v EC/�� �.�1 G A
has been installed in ccordan e with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated –�� Approved Design Flow�_W (gpd)
Installer _ I/(// j. - �w _
Designer: .4�Al e`,O� Inspector: Date: / f
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. %�l// �l/%�/ FEE
COMMONWF-AIT14 Of MASSACHUSETTS,
Board of Health, A,�04/7-,V, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereb granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at ��� r as described in the application for
Disposal System Construction Permit No. d� ` 7 , dated
Provided: Construction shall be completed within t4fe• =-,r s of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /� �� Board of Health