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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 06 FEE �-7n 4 C®MMONWUALT14 Of MASSAC14USETTS Board of Health, /darn au -% A , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) UpgradeKAbandon( ) -Complete System ❑ Individual Components Location 3 ij f Owner's Name Map/Parcel# �v Address Lot# Telephone# Installer's Name A & B CANCO Designer's Name s Address 350 Main Street MA 02673 Address Telephone# , Telephone# Type of Building Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. requ. Plan: Date Title Description of Sdil(s) _ Soil Evaluator Form No Lot Size No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) req) �5^J^� gpd Calculated design flow Design flow provided �Lpd Number of sheets ( Revision Date flo6 a_re—Q -Co,n L.�-z Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS `DCe—r 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 no to pl�e system in operation until a Certificate of Co ana has been issued by the Board of Health. g Signed Date Q Inspections No. A � � FEE COMMONWEALT14 Of MASSAC14US ETT Board of Health, /1-) % , ) 10 i�, I h , MA. tk(j CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 'Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (%Abandoned ( ) by: C' "d /U K at 'Al%C ilr Ai(� LI//lel has been installed incc a e with the ro 'cions of 0 CMR 15.00 (Title 5) and a oved design plans/as-built plans relating to application No. ©� dated 7 Approved Design Flow �? (gpd) Installer . � � ii1 �� n Vi 17 - Designer: _y Thessuance of this permit shall not b C®MMONWEAILT14®F MASSAC14USETTS Board of Health, Yla r M vv I- k , MA. `(Wt-' Inspector: V UL4 pC &IZ Date: W construed as a guarantee diat the system will function as designed. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEES Permission is 4ereby rante to; Construct( ) Repair( ) UpgradA.) Abandon( ) an individual sewage disposal system at [ / as described in the application for Disposal System Construction Permit No. _ 1 , dated Provided: Construction shall be completed within thre�s of the date of thisy�r t. All local co ditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date, v Board of Health