HomeMy WebLinkAboutApp-Permit-ComplianceNo. 404!�-- 7 zoo - Z FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA. '✓ j�� wL
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( rade( ) Abandon( ) - ❑ Complete System Individual Components
Location oZ rl-,f % o C4- 01 „Tj
Owner's Name
Map/Parcel# O� - _
Address c2 ),:,Lg% lfaCk Xjo J- AW
Lot#
Telephone# J-4 j'`- ` -Lll %/
Installer's Name �,e X/U(-®
Designer's Name
Address 15-0 IvAlIv ST w-10% fle
Address
Telephone# 3"0 p' - r) 9 5'- 6 FO 40
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.
Ou
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS ORALTERATIONS ir{ E,40!4 /YC
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a 761T
to not to place the syst in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No.
COMMONWE- LT14 Of MASSACHUSETTS
Board of Health, Xy/p MA. —,J6 y
, J6y
CERTIFICATE OF COMPLIANCE
FEE
oH�
Description of Work: 8<dividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandoned ( )
at a /f3 -. O Y� r2
has been installed in acc dance with the rovisions of MO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
applicatio,�'�lo. 0 S - k-7 , dated Lp -0 � . Approved Design Flow (gpd)
Inspector:
Date: -3/?V—OS
0S
The issuance of this permit shall not be construed as a guarantee that the system vi 1 function as designed.
N..0'; --F7 Ca Az{) FEE
Board of Health l /P MA. zDISPOSAL SYSTEM CONSTRUCTION PERMIT
�i%
Permission is hereby granted to; Construct( ) Repair( 43-Vpgrade ( ) Abandon( ) an individual sewage disposal system
at %�.�/�%_ �l O �l %,�� .5-49 T -
as described in the application for
Disposal System Construction Permit No. QS- e-7 , dated-
Provided: Construction shall be completed within r of the date of 7hU'Crizt. to al condition st be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Dat / Board of Health