HomeMy WebLinkAboutApp-Permit-Compliance� 60q!��4-240M >&V - )
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ��y MA.
FEE
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APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repapgrad ( ) Abandon( - U Complete System ®'Individual Components
LocationS 5-�
Owner's Name
Map/Parcel# k-a�e
Address S 5
Lot#
Telephone# - ,
Installer's Nam \� —` c
Designer's Name
Address�� .
Address
Telephone#
Telephone#
Type of Building z ] Z ..a cj Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Sbil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �;����G.-� �( - �v✓'� C� �i� -� .
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 to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ 1 Date -�
Inspections
COMMONWEALTH OF, MASSACHUS
Board of Health, MA.
*�Y'/)'FEE ` (l U
r
Description of Work: CKridividual Component(s) Q Complete System 7
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (yjjUaded ( ), Abandoned ( )
at
has been installed in accorda ce with the provisions of IO CMR 15,00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated f' -- " Approved Design Flow (gpd)
Installer : k I
Designer: Insp
The issuance of this permit shall not be construed as a
No. t20kADC Vi FEE .55, 00
COMMONWEALTH OF MASSACHUSETTS 4*3 Z --a 3
Board of Health, MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(Vl-Upgrade ( ) Abandon( ) an individual sewage disposal system
at�as described in the application for
Disposal System Construction Permit No. —S dated. 3::��=.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestotin, MA Date 77 Board of Health- 1 .�-