HomeMy WebLinkAboutApp-Permit-ComplianceNo.�a�fbG�17 ��� / \`IO FEE �r
COMMONWEALTH Of MASSACHUSETTS
Board of Health, y4g*�117 V:[!A , MA.
APPLICATION FOP DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrad�andonO leomplete System 0 Individual Components
Location
Owner's Name
Map/Parcel# na
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address 3 0 i �P
Address
r
Telephone# ver— -y zS7 r lL.
Telephone# �� f
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 &Cd? Garbage grinder( }
Other- Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (mina required) 33 gpd Calculated design flow Design flow provided =3 gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s) ,� �d
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 agr to not to place the system in operatio ntil a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No.;> �,�jj FEE dU
Va... 9- 7>
7 �' CONI MONWI;AL.TH OF MASSACHUSETTS eke C� 0
Board of Health, VA9 MA i MA MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) spdinplete System
The undersigned hereby certify that the`Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(-j;'AXbandoned ( )
by: 44
at
has been instal
application No.
Installer 11
led in acctiidance;wi•th,'the ]Sr wast t(s'm1M10 CMR 15.00 (Title 5) arrd the a roved design }glans/as-built plans relating to
% dated Approved Design Flow _ � (gpd)
Designer: �i `nom -1 —197
Z
The issuance of this permit shall
y
No.72e117)1-1?-
7 ;� ,,>., COMMl ®NWEAL.TH OF MASSACHUSETTS
Board of Health, �A9=Ma%MA MA.
DISPOSAL SYSTEM STEM CONSTRUCTIONPERMIT
FEEL
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at r r % �' as described in the application for
Disposal System Construction Pe it No. 7—j4 , dated
Provided: Construction shall be completed within throof the
oate of this per i Notal conditions must be met.
f.Form 1255 Rev: 5/96 A.M. Sulkin Co. ChadeStown, MA Date � I` � Board of Health