HomeMy WebLinkAboutApp-Permit-ComplianceNo. ✓ ts.' If� A*eCal&7-11
FEE
COMMONWFALT14 OF MASSACHUSETTS
Board of Health, Zg .-.oro ee , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION
�PERMIT
Application for a Permit to Construct( ) Repair(1,<Upgrade( ) Abandon() - ❑ Complete System &'Individual Components
Location 9
Owner's Name
Map/Parcel# 3
Address �s
Lot#
Telephone#
Installer's Name o'er
dr .
Designer's Name
Address
Address
Telephone# 2���r—
Telephone#
Type of Building _S'.o�y��',,Jv 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) :3 3e::P gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS
%
�CJ t e- 1 /' GZ G -!-"- :7�2'12
gpd
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 lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ter --moi Date
Inspections
No. O N' U e3() O f�i I/ FEE
COMMONWEALTH Of MASSACHUSETTSA -7�
Board of Health, MA. �� 1
CERTIFICATE Of COMPLIANCE
Description of Work: Wfndividual Component(s) O Complete System 7( Ko
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),`Repaired (,-UpgradedAban ( )
by:
atl'
has been installed ' cco a ce with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated l J7— f� Approved Design Flow `�-" (gpd)
Installer
Designer: -""" Inspector: ." (�� ���� d� Date: ^--)-0 ^ 4�
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. Qk r- —���� l. -f &b of n eiz-V:cE5 FEE iS 00
COMMONWEALTH Of MASSAC14USETTS
Board of Health, f `r'otL_� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) RepairU Upgrade( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. -' dated —,)--
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit.All-local conditiow must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � � / ` � 'OBOard of Health
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