HomeMy WebLinkAboutApp-Permit-ComplianceNo. C/ J ' F 1,,I-Ite A" FEE A/0 l e
COMMONWEALTH OF MASSAC14USETTS
Board of Health, `/' l , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(lf""Upgrade( ) Abandon( ) - ❑ Complete System lrI dividual Components
Location % D /n A 7-4 l �l £C. /t�17 S �j9
Owner's Name l A V. l D 6 / cid,
Map/Parcel# j�Z
Address % /4 C Al F r �`� `� YAR
Lot#
Telephone#
Installer's Name 1 A N C d
Designer's Name
Address I)I A /N 37- LtJ - yx
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
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
Lot Size
No. of persons
DESCRIPTION OF REPAIRS OR ALTERATIONS 4 IN Z C ,�Iiq N,K
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ees to not to place the system ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /d �� 7' ^ 03
Inspections
No. V � � /
COMMONWE4LT14 Of MASSAC14USETTS
Board of Health, //� /� MA.
CERTIFICATE Of OMPIJANCE Z�Ae
FEE
Description of Work: 3 Individual Cpmponent(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( j; Upgraded ( ), Abandoned ( )
has been installed in acc5o{ with the provisions of
applicationo. (,/ ��/ - dated l
Installers/i1�--�a+-
0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow �- (gpd)
g p J id�9f�� t��f
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 3 /// ! `e �! FEE t
COMMONWEALTH OF MASSACHUSETTS
on
Board of Health, �/� MA. C �V//.
DISPOSAL SYSTLM CONSTRUCTION PERMIT 70
s,
Permission is hereby granted to; ConstructO Repair ( Upgrade ( ) Abandon ( ) an individual sewage disposal system
at . G% RD _50 as described in the application for
Disposal System Construction Permit No.0 �eF, dated
Provided: Construction shall be -completed within_thr o the date of this permit. ,All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date /0 :. 2,4 (%Board of Health / '' , f