HomeMy WebLinkAboutApp-Permit-ComplianceNo. J �L / -C q 1"as to,,( FEE
COMMONWEALTH Of, MASSAC14USETTS �&_ P� 5"
VAJ-DAUUTH HEA -11 EP T.
Board of Health,T
11 4S RG .
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APPLICATION FOP, DISPOSALEWMMM"PIRVON PERMIT
Application for a Permit to Construct( ) Repair,-19Upgrade( ) Abandon() - ❑ Complete System ❑)Individual Components
Location �/Zd
Owner's Name S
Map/Parcel#
Address C 2
Lot#
Telephone#
Installer's Name D
Designer's Name
Address
Address
Telephone# jam$
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd . Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder( )
Showers ( ) , Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to ),place the Aem in operation until a Certificate of Comp 'ance has been issued by the Board of Health.
Signed Date O
Inspections
Lr
No. D / Z� '� G� FEE
COMMONWEALTH Of MASSAC14USETTS d"o
Board of Health,1,1,4f / t// MA. _
CERTIFICATES dF COMPLIANCE 4W
Description of Work: C Individual Component(s) ❑ Complete System
The undersigned ereby certify that the Sewage Disposal System; Constructed ( ), Repaired j�pgraded ( ), Abandoned ( )
by: ��
at
has been installed in accorda with the provisions of 310 CMR 15.00 (Title 5) and�the approved desi plans/as-built plans relating to
application No. 6)S 24 dated ApproWd Design Flow (gpd)
Installer /,5Ll%.
Designer: Inspector: 1,.,1 C/� Date:
The issuance of this permit shall not be construed as a gudrantee at the system will function as designed.
FEE 1
Board of Health, LZA1,VakMA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(n Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 1 C`7wg-e Z&f' as described in -the application for
Disposal System Construction Permit No. a� dated 7-1926.
Provided: Construction shall be completedwithin t iters of the date of this er it l local condition ust be met.
6�v5
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ` %LS r,'K Board of Health