HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0t41) FEE i 5r 000
COMMONWEALTH OF MASSACHUSETTS
Board of health, A�VT4 , e
APPLICATION �®�. ��������SYSTEM ���N�T�J�TI�N PERMIT
Application
Application for a Permit to Construct( ) Repair) Upgrade( ) Abandon( - ❑ Complete System VIndividual Components
Location
-.5' Owner's Name Pe1W le4ll&.f
Map/Parcel#
`�.
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address % r
�� C�i%y��°2 Address aa, _Z -V-5 W
Telephone#
0 „ 0 SF
J Telephone# 7 7 5 -
Type of Building 01 A I,ot Size sq. ft.
Dwelling - No. of Bedrooms 6Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
7 �
Design Flow (min. required) 1 .3 gpd Calculated design flow
Plan: Date - Z Z M % Number of sheets
Title
Description of Sbil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Design flow provided gpd
Revision Date
g L Date of Evaluation 3- 9 IS
DESCRIPTION OF REPAIRS OR ALTERATIONS � � y i✓ SAE
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 syste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �r�% Date �� v— Date L
Inspections
yam,
No. -& � � `l..+C -� �-"� �� FEE
COMMONWEALTH OF MASSA�flUSETTS
44 - 1
Board of Health, V42? 6 t � , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: individual Component(s) ❑ Complete System X
The undersigned hereby certify that'lie Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(.• -!Abandoned
by: � fi f, i r
at
has been installed iniac ance with the rovisioAns_ of 3_10 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �(r , dated ���• Approved Design Flow _(gpd)
Installer /4a' %"E s e Af
Designer: R o .A Inspector: 0Date:!
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.;_.:, _
No. 000MMONWEALTH OF MASSACHUSETTS
('�
FEE 4!25:a
—
Board of Health, \6:7MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade (✓) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed withirLaa�, `swthe date of this permit. 1 local conditiot must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown,MA Date—__ , —1 ° Board of Health