HomeMy WebLinkAboutApp-Permit-ComplianceNo. ark! —10
7
COMMONWEALTH OF MASSACHUSETTS
Board of Health, )6j:??M(J4�T?4 , MA.
FEE' /
APPLICATION FOR DISPOSAL S ]1ST ��1� TRUCTIO1� ,PERMIT
Application for:a Permit to Construct( ) Repair( ) Upgrade( -1 - Complete System ❑Individual Components
Location „7 5-
flo>7
Owner's Name
Al -be
Map/Parcel# AkZ,44
!/Lt
Address
Lot#
Telephone#
Installer's Name
Designer's Name��
"
Address
Address
Telephone#7'7
— ��
Telephone#
—_
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms A: Garbage grinder
Other -Type of Building No. of persons Showers ( ),'Cafeteria
Other Fixtures
Design Flow (min. required) D gpd Calculated design flow_ Design flow provided gpd
Pian: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with theprovisions-of TITLE 5 -and
further ,agrees
itoo p Mace the syste� 'n oge on until a Certificate of Compliance has been issued by the Board of Health.
Signed ��/ """ Date
Inspections2//�
No.FEE
COMMONWEALTH OF MASSACHUSETTS
> � Board of Health, y��M 6(2n , MA
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) mplete System
The undersign `d hereby certify that ie Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded4—)—,Abandoned
( )
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the aproved design plans/as-built plansrelatng to
application No. - dated. Approved Design Flow c� (gpd)
Installer
Designer: 1 rfspector:
..16tzDate:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No �' /� f / "� l C tai' FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, AMAQ ( 2771 Pm.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (✓f Abandon( ) an individual sewage disposal system
at _—;2 5 / � �7 Y� :�-? as described in the application for
Disposal System Construction Permit No. dated -. 7
Provided: Construction shall be completed within->lr eater, oft e date of this pdr nit. ;All local conditions must be met.
Form 1255. Rev. 5196 A.M. Sulkin Co: Chadealown, MA Date .2 "" -7- / .Board of Health