HomeMy WebLinkAboutApp-Permit-ComplianceNo. PO oliz, 49 b 0 '{ 2-8 q FEE'
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, �61►'c► , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( Repair(UpgradeO Abandon( - Complete System O' Individual Components
Location a Avet+
Owner's Name_ int
Map/Parcel#
Address 9-7 _ .- i e � L_
1 oeL A&A
Lot# i 8
Telephone# --
Installer's Name r
Designer's Name E AS CgyN in c,
Address q .
AddressPO 0X 1-12q (ah,1WU MA 02W
Telephone# 2 -
Telephone#
Type of Building -
2 .3d inj)iX,S-G Lot Size Y & O sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers ( ), Cafeteria ( ).
Other Fixtures
Design Flow (min, required) y gpd Calculated design flow ,3,?k3 Design flow provided gpd
Plan: Date 1 !� b Number of sheets _ Revision Date
Title e
i
Description ofSoil(s) _ f 0 ku-1 R 1 nim / mfU2, sa
Soil Evaluator Form No. i 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; agrees, to t to lace the tem in operation until Certificate of Compliance has been issued by the Board of Health.
Signed U Date
Inspections
t
CA
r�• j�
COMMONWEALT14 Of MASSACHUSETTS �S 0 K FEE
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Board of Health,
41FICATE Or Cj9M%,V1gq
Description of Work: Individual Component(s) olttptle Syste' I [[ I QAl
i¢p
The u dersigned hereb c xtifry that the Sewage Disposal System; Construdted t( . $R p^fired (e);> L�LPg ded ( Ab d ned ( )'
by:
at �r b�, 1-JAkm/� }tll
has been installed in cco an e with the provisions of 3),oG6R U.00 (Title 5) and the approved design plans/as-built plans relating to
application No.dated. ?� ~f�. Approved Design Flow (gpd) 1
Installer
Designer:lL_� 1 �%%. � Inspector: Date: _
The issuance of this permit shall not be .construed as a, guarantee that the system will function as designed.
-51
1 ONWEALTH Of MASSACHUSETTS
Board of Health, Y&ft 0VrV " , MA.
DISPOSAVI WSTEM CONSTRUCTION PERMIT
i
FEE D Q10
2-1. "wS-
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,(.) Abandon( ) anindividual, sewage disposal, system
atW -qt z r as described in the application for
Disposal System Construction Permit No.
Provided: Construction shall be completed within
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date
ars of the date of
Board of Health _