HomeMy WebLinkAboutApp-Permit-ComplianceNo. bb4i��--- �u t� ,sem,„/�-ti/ p l`."a','sE"ej{ PEE i,96%XO
COMMONWEALTH OF MASSACHUSETTS �7
Board of Health, �Yrrr.�lrii 2� , NIA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication fora Permit to Consuvet( ) Repair(z Upgmde( ) Abandon( ) - ❑ Complete System t1l dividual Components
Location7.—
Owner's Name
Map/Parcel# /v��y,
��y
Address 7
Lot#
Telephone# oy� TS -6cPSd
Installer's Nam
Designer's Name
Address
Address
Telephone# —o�y > ,.._.
z3`
Telephone#
Type of Building eL �_ �-C"Cel Lot Size
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
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
sq. ft.
Garbage grinder ( )
Showers ( ),Cafeteria( )
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS%:f.�`.>_
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to/not
"tto place the system in operation until a Certificate off Compliance has been issued by the Board of Health.
Signed /�:..�� Date i//i/�'
Inspections
No
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth, " MA.
CERTIFICATE OF COMPLIANCE-
Description
OMPLIANCE
Description of Work: Ellndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired
has been installed in ac
1r
application No. i"
Installer-'.z7��
,
PEE �..,i .w.?.. 00
Abandoned
with theprovi{�t/oits o6(�'._r310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated_. %� 4s . Approved Design Flow -"`"`_`- (gpd)
Designer: Inspector: 'la />/ C.. tr t,a! 1 Date:
Tile issuance of this permit shall not be construed as a guarantee that tl a system will function as designed.
No.fCC
COMMONWEALTH OF 1MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
PEE
Permission is hereby granted to; Construct( ) Repair (a-wr Upgrade( ) Abandon( ) an individual sewage disposal system
at '1 � Ss" e','• , , as described in the application for
Disposal System Construction Permit No. fK `" f)t P , dated;_
Provided: Construction shall be completed within three years of the date of this permit. tlll local conditions must be met.
k
Farm 1255 flea 6198 A.M. Sultrin Co. Boson, MA Date/__P'
/,,(" BOat'd Of 1-lealth