HomeMy WebLinkAboutApp-Permit-ComplianceNo. 49 _ FEE
COMMONWEALT14 Of MASSAC14USETTS
Board of Health, WRIVIOUTHHE _
APPLICATION FOP, DISPO�
M, 6Q&IWUCTION PE MIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ Individual Components
Location 7
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Owner's Name
Map/Parcel#
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Address `.r7
Lot#
Telephone#
Installer's Name
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Designer's Name -�
Address
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Address
Telephone#
sY - & a
Telephone#
Type of Building
Dwelling - No. of Bedrooms _
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
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Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS l2 'PAR A -e 02/7 G f I' -P,at S- /`Ze'�`�
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The undersigned agrees to ' stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ees t not pla to in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date _ �" -I
Inspections
No. Sr� BUCOMMONWEALTH OF MASSACHUSEPTIiE
y
{Board of Health, f 11,�c W •;�1 , MA. �
CEPITIFICA�f Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: {�i� br-Cc -,�,, �r
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. b dated./ Approved Design Flow (gpd)
Installer 1- I , 3 rcl) i CA Cc ^ j %l /1 _! 17 �
Designer: Inspector:�t. ri Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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'l..OMMO1V` V'I' 11' ALT14 ®f MASSAL-iL�t i SETT
Board of Health, �i. �' MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at -P1XC,,-4 P, as described in the application for
V
Disposal System Construction Permit No. J dated
Provided: Construction shall be completed within �s the date of this permit: All local conditions must be,met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date oard of Health /��`�-�--�/� �/�.✓`-'C f � ��//