HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
C®MMONWEALT14®f MASSAC14USETTS
Board of Health, ,41 /\ , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(Afllpgrade( ) Abandon( ) - ❑ Complete System U�r<dividual Components
Location 3,0 eL £h/PBii' ook RD ju• -
Owner's Name C// -,a f/p 7`` 'D / L L is ti
—40
Map/Parcel# 6Z�,q
Address 7,0 CIL r,41? RAP oh- t,� ` ,4
Lot# r
Telephone# r2 SG f x G y
Installer's Name C 4 Ne Q
Designer's Name
Address 3 �U �ryJ, 5 ? _ �/��o
Address
Telephone# -5-,0r- 09f- A fvo
Telephone#
Type of Building / U S Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
QiSCRIPTION OF REPAIRS OR ALTERATIONS M A / A�- /
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o not to place the system in o eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ? -1&1-,o 3
Inspections
No. 6 _� J � FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 7= l'�" , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U4' ividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4<Opgraded ( ), Abandoned ( )
by. � �'c�—� /f/ co -3 E 6> �'i 5 T 44, t1�J %'
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicationIAZO
"-�_..dated Approved Design Flow ^--• (gpd)
ller
Instal �_
The issuance of this permit shall not be construed as a guarantee thatlkh`e system will function as designed.
No. FEE ! Y C
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ydze , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby'�granted to; Construct( ) Repair( L)- Upgrade( ) Abandon( ) an individual sewage disposal system
at 'pie` d 1f d l? GG%' IP,)I G, - t+' /a/tp as described in the application for
Disposal System Construction PerYrnxt Ldated=�
Provided. Construction shall b pleted within three years of the date of this permit. All local conditions must . met.
Form 125§ Rev. 5/96 A.M. Sulkin Co. Boston, -MA- :X Date7—/ 0 loard of Health 1
AP.
x