HomeMy WebLinkAboutApp-Permit-Compliance& 00
L�1 4 a
FEE
COMM0
Board of Health, �<Hoezl-1 , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (41y' -`Upgrade ( ) Abandon( ) - D Complete System individual Components
Location
Owner's Name
Map/Parcel# /G
Address S,,,
Lot#
Telephone# �f� yG �•
Installer's Name
Designer's Name Z11-1111--y-
Address
Address f-�
Address
0
Telephone# `o 7S— _
Telephone# 2 _
Type of Building Je
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
r
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) Z CJ gpd Calculated design flow Design flow provided 51P gpd
Plan: Date 9/.f/i- Number of sheets Revision Date
Title 44Zj2 5�- Sim rd�2.✓!
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1% � seri f/�-�� �,?—/�asr . 2 " -f—,V,1 lrQ
e— Z—, 04gne. 5r ,'f t/, --/' A211 8.1 mar Zs- :F 2 ,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre7;=-
place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed — Date
Inspections
?---4 --/ 7 4�- 4 old 6q t
No. i / 6 A ID - I,% -!_i q ZJn1 FEE � 5..o. Co
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Z ndividual Component(s) ❑ Complete System
The undersigned hereby certify t t the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned ( )
r
by:
at �i'r5 .ffi ,� di �s /e
has been installed in accordayce with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. i—/ dated /�` `% Approved Design Flowgpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantye that the system will function as da:signed.
No. D C "I 7 _C 'i 2-91 4E -e V I FEE V DO Y
`7-.) k/ COMMONWEALTH OF MASSACHUSETTS -2-1 1
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) �Repair(1�'/Upgrade( ) Abandon( ) an individual sewage disposal system
at �Z -- � c�� Z�/ as described in the application for
Disposal System Construction Permit No. /, dated //---F—/.7
Provided: Construction shall be completed within Ke date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date// -4—,/7 Board of Health d.rs•"