Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
App-Permit-Compliance
No. lo WY/ C4 v — 22-73 "Y f! 3 5 FEE 19'.76 COMMONWEALTH Of MASSACHUSETTS &*j �'�� Board of Health, _Y� �i �" , MA. APPLICATION FOR DISPOSAL SYSTEM CO CTIO PERMIT Application for a Permit to Construct() Repair() Upgrade Abandon() Complete System ❑ Individual Components Location/ Owner's Name l Map/Parcel# Address Lot# Telephone# , Installer's Name Designer's N Address v/ Address Telephone# Telephone# _ Type of Building _ Dwelling - No. of Bedrooms Other - Type of Building No. of persons Lot Size sq. ft. _ Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures r Design Flow (min. required) gpd Calculated design flow Design flow provided !2 gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation The undersigned agre to install above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre o not place tem in operation until a Certificate of omp 'ance has been issued by the Board of Health. Signed Date 1 '' Inspections t COMMONWEALTH OF 1° llASSA'l..HET�T Board of Health, `7AOMDO1 t'. , A". 2e t1B CERTIFIC TSE.OF COMPLIANCE Description of Work: ❑ Individual Component(s) ,.Complete System P The undersigned hereby certify that the Sewage Disposal System; Constructed,( ) , Repaired ( ), Upgraded Abandoned( ) at has been installed in cordance with the provisions of AO CMR_ 15.00 (Title 5) and,the a roved design plans/as-built plans relating ito application No. 'dated. Approved.Desigri Flow (gpd) Installer144 Designer:"" i?s vr4 , i3 ,'. .�►' '.;SG�tI Inspector: &56 Date: r The issuance of this permit, shallnot* construed as a guarantee that the system will function as designed: crv:cc�oc�o�ov -orr,ovaur�coo c;coc000�eo9oo[>�cnor fSaOGOOdOCl:00-UOOUGGGOpGOObOOGU00[:<"GOOOGCJ<OGO�JJOCOOGOOOyl'UOGCOU009C.;Go43000cetic No. oyk _ u— a��y `2,.� �•1 FEE COMMON LTH Of MASSACHUSETTS fit, -Board of Health, X10, --O STM O LTij+ �,IWA. p� DISPOSAL S�YST [ CONSTRUCTION PERMIT ` Permission is hereby granted to; Construct( 1f Repair( ,� UpgradeAbandon( ) an indi�ddual sewage disposal system at ,�! � ©t 9 A?4 /,0V� � as described in the application for Disposal System Construction Permit No. A*1-76 dated Provided: Construction shall be completed within �rsrofthe da;ofthnis All local cond�'ons must be met. Form 1255 Rev.5/96 A.M. Sulkin Co. Chadeslown, MAA,C/�'Date Board of Health n.