HomeMy WebLinkAboutApp-Permit-ComplianceNo. (/ 6-146 FEE
VAPKAn HTH HEALTH
Board of Health,1146 ROUTE 28
D,'�V1A.'
/Application for a Permit to Construct( ) Repair( ) Upgrade (e4Abandon () - ❑ Complete System Jr Individual Components
Location , �G/_(
Type
Owner's Name
Map/Parcel#
Address
Lot#
Name of Soil Evaluator Date of Evaluation
Telephone#
`
Installer's Name -1�
Designer's Name
Address /�J p ti
���� L W� ✓�
Address J
No.
Telephone#
X-,0
Telephone#
_ 35;.2.2 -
.2-
Type of Building 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) gpd Calculated design flow _`Z -D Design flow provided pd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS .�'t �✓'� /d �'"� l��/(!G L �iO�/`J` �°� �'1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not t lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signe Date �X;2 2��
Inspections!
No.
COMMONWEALT14 Of MASSACHUSETTS FEE
Board of Health, ®'�//'��/' MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U151vidual Component(s) ❑ Complete System
The undersigned hereby cerqfy
by:7
at `
that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (--Abandoned ( )
has been installed in accordqncQ
application No.
with the provisions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
, dated " e2Approved Design Flow 3 gPd)
//
Installer
Designer: SW CX 1 �
j" %V / X&'_ Inspector: (5—' A \ Date: U
_The issuance of this permit shall not a construed as a guarantee that the system will function as designed.
No.
C/(_% (�' ' f/� /�1� FEE
COMMONWEALTH Of MASSACHUSETTS -4- �6f
Board of Health, Vat pwo �6 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at 2=2 f� LGly,,y /J -1 • as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within t .rs of the date of thi4pmlt,llocal conditioi3 must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA/ (� Date/ `." / " �B and of /HealthL%x�?
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