HomeMy WebLinkAboutApp-Permit-Compliancel No.
FEE
COMMONWEALTH OF MA�%P§ETTS 41
HEZ
Board of Hea44AS F Cf: ii E 28 , MA.
APPLICATION FOP, DISffiff"AW6MTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - ❑ Complete System Individual Components
Location f ,
Owner's Name
Map/Parcel# 7,
Address i
Lot-# g�
Telephone#
Installer's Name Q`���c t
Designer's Name
Address G� JC
Address
Telephone#
Telephone#
Type of Building �t C.sl�y� Lot Size `5 / sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No,
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS rX51,71
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no to lace e s tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 7-30-03
Inspections
No.{✓ f
COMMONWEALTH
(� FEE
'L_.®MMO V'V' EALTH OF MASSACHUSETTS
f r �i�j MA.
Boarrd o Health, ,(
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) ❑ Complete System
The undXiV97
C.._.d hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded K,"Abandoned ( )
by: �G / ele,5
at 7 16AL-11it-
has been installed in accordant with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. U `.,' -� dated 7- Approved Design Flow (gpd)
Installer JCtYL -lei L C
Designer: Inspector: (—A V Date:
a
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. co, �./� fi / �� FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT *y
Permission is hereby granted,to
at
Repair( ) Upgrade (,V) Abandon(
an individual sewage disposal system/
_ as described in the applicati"'for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within 4trl . i3s Ahe date of this permit. All local conditio s must be met.
f
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date? ?& Board of,Health '