Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1 FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, 7 0 , MA. APPLICATION FOP, DISPOSE: SYSTEM CONSTRUCTION PERMIT Application for a,Permit to Construct( ) Repair�4/upgrade( ) Abandon( ) ❑ Complete System®"Individual Components Location to le, 5 Owner's Name Map/Parcel# . Dwelling- No. of Bedrooms Address Lot#: Garbage grinder Telephone# Installer's Name Designer's Name Address[I l� I� ©�,�p`t Address Telephone#50S 1-k0 t6pQ i q 7VZZ2q Telephone* Type of Building le, 5 Lot Size sq. ft. Dwelling- No. of Bedrooms Garbage grinder Other - Type of Building No. of persons Showers O,'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 DESCRIPTION OF REPAIRS OR ALTERATIONS �Ct9f1Lk�— The undersi a agree o ins further;agre t no lace Signed b em in edividual Sewage Disposal System in accordance with the provisions of TITLE 5 and scribed In operation until a Certificate of Com ice has been issued by the Board of Health. Date Z— W� Inspections No.. FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, Y qgm b um , MA. CERTIFICATE Of COMPLIANCE f Description of Work: ;d'Individual "Component(s) ❑ Complete System A,? O� The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ,,.Upgraded O, Abandonedby: ( )` I, � , at 11 has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as.-built plans relating to application No. f "' 8 dated iC, .Approved Design Flow (gpd) Installer 1_1% `F ~` �1i t - Designer: .......-.---- Inspector: Date: jzno>' The issuance of this permit, shall not be construed as a guarantee that the system will function as designed. - -- No:: _>t •-1 FEE' COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. DISPOSAL SYSTEM NSTRUCTI®N PERMIT Permission is hereby granted to; Construct( ) Repair ) Upgrade ( ) Abandon( ) an individual sewage disposal system at l Disposal System Constr ction Permit No. tco'r �— dated a- CV as described in the. application for Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5196 A.M.SulkinCo. Chadestown,MA Date 1 a iJ Board of Health