HomeMy WebLinkAboutApp-Permit-ComplianceNo:
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COMMONWEALTH Of MASSACI
W Board of Health, y�P �� , MA.
> APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMI1
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FEE 4675-.60
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Ap ication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - -9-Complete System ❑ Individual Components
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Ication
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Owner's Name
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Address
Lot#
Telephone#
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Installer's Name
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Designer's Name
Address
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Address
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Telephone#
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Type of Building - - r ��, i 1 Lot Size C q. _ %1—sq. ft.
Dwelling- No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mi . required) Ilo gpd Calculated design flow 1100 Design flow provided J1 QQ gpd
Plan: Date Number of sheets i Revision Date 3 b i l a gi b
Title
Description of Soil (s) W .5'-e % S
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
OF REPAIRS OR ALTERATIONS T'-A<&/L. -DS-6V . U"
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of gomplianceyhas been issued by the Board of Health.
No. �Q � C�{�-1���COMMONWEALTH Of MASSACHUSETTS � :�� ��
Board of Health, O , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) .Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( }; Upgraded Abandoned (
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has been installed in ac ordance with the rovisions of 31 MR 15.00 (Title 5) and the approved design plans/as,-built plans relating to
application No ,dated '' 'F --'� I — AApproved Design Flow i t; tip (gpd)
JrKInstaller 14. KJ4L-- »
Designer: �.,�� �:C Inspector: /� (10 l_. Date: 5
The issuance of this permit shall not be construed as a guarau#eee that the system will function as designed.
No. 600 1. i :J FEE �� )
COMMONWEALTH OF MASSACHUSETTS
Board of Healtla,{zivto, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran ted to/; Construct( ) Repaix`(, Z Upgrade ( ) Abandon ( ) an individual,sewage disposal system
at -7 Ale � - as described in the application for
Disposal System Construction Permit No. — 7 , dated C�
Provided: Construction shall be completed within three years of the date of thi7per itit� All local condi' ns must be met.
Form 1255 Rev. 5/96 A.M.;SulkinCo. Chadeslown,MA Date /PBoard of Health