HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60 - f 2,475- FEE 65 & M 1
COMMONWEALTH OF MASSAC14USETTS
WBoardofHealth, �� vv2'oce� , MA.
P/4 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
9� kiplication for a Permit to Construct( ) Repair (t�Upgrade( ) Abandon( ) - l"Complete System ❑ Individual Components
location U Owner's Names
ap/Parcel#
ot#
's Name
Telephone# 5-.�A. -', r -i
Type of Building Z "'Ak- +
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required) 30
Plan: Date /Z' 44'4-- D\
Title 7 i7 , .s- 'rr!/e
Description of Soil (s) �lrrcr
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR
i�..� FS i/drip
Name of Soil Evaluator
�� c , 2, 1 1/ °r 4-/, I-V- S' "1
_ Lot Size /ST-_ sq. f�.
Garbage grinder ( )
s Showers ( ), Cafeteria ( )
:sign flow provided :33 3 gpd
on Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to snot/to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Z�I�x//-47
Inspections
u /
COMMONWEALTH Of MASSACHUSETTS
(1741 Board of Health,
CERTIFICATE Of COMPLIAN,�
Description of Work: ❑ Individual Component(s) &Complete System
The undersi ned hereby certify tha the Sewage Disposal System; Constructed ( ), Repaired (e'j graded bandoned ( )
by:
at
has been installe acc nce with the provisions of410 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
ati
applicon No. I- dated ® _ . Approved Design Flow3 -3 (gpd)
Installer
Designer: Inspector- Date:
The issuance of this permit shall not be construed as a guar tee �thtthe system will function as designed.
No.� �C- �-' 'I J% :: i�4"P�COMMONWEALT14 OF MASSACHUSETTS
Board of Health, d,,, i7'4 , MA.
DISPOSAL SYSTEM
FEE��
.Z--7
Permission is hereby granted to; Construct( ) Repair(1-6pgrade� Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No., date
Provided: Construction shall be completed within ears of the date of this per r10
. ocal conditions must be met.
`) 1
Form 1255 Rev. 5/96 A.M. Sulkin C . Boston, MA Date —i Board of Health _. '