HomeMy WebLinkAboutApp-Permit-ComplianceNo. ..-a FEE
COMMONWEALTH OF MA ����J �S 7991
Board of Health, 114(-' Rf"UIE 28 MA.
APPLICATION FOR DISPOSH-MWMANCTION PERMIT
Application for a Permit to Construct( ) Repair (-,,`Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location Vj'�,
Owner's Name
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t 1
Map/Parcel# ,Z� 1
Address C) (5
S V n,,�l 0 ^t"
Lot#
Telephone#
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Installer's Name LO r �
Name
nDesigner's
Address 1 i-WA%\'j
Address ,T rzd S
Telephone# cjC)b(,Telephone#
SM
Type of Building �'Cl�� '2SK�— Lot Size /Alb 5 % sq. ft.
Dwelling - No. of Bedrooms I�rGarbage grinder #Q
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) . gpd Calculated design flow Design flow provided S 7S ! gpd
Plan: Date cJuW 10 ( 0-7 Number of sheets Revision Date
Title I
Description of Sdil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 place the system in operation until a Certificate of /Com fiance has been issued by the Board of Health.
Signed Date /d/ � pV —7
'iEl
COMMONWEALTH Of MASSAC14USETTS
Board of Health, G W-101 f i' ` MA,
CERTIFICATE Of COMPLIANCE
Description'of Work: ❑ Individual Component(s) Ercomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),,Repaired Upgraded ( ), Abandoned ( )
by:
.at Ay
has been installed in ac ora ce with the,,PProvisions of IO.CMR 15,00 (Title 5) and the a roved design' plans/as-built plans relating to
applicationNo. dated / Z �j d Approved Design Flow 7q. (gpd)
Installer S C O r-%— r(
,rf
Designer: w? -e SL IC _ Inspector: Date:
The issuance, of this.permit shall not be construed as a gu antee. at the system will function as designed , --
FEE
C®MM®NLTH OF MASSACH,USETTS 7??i
Board of Health, MA. i„�'tfw
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( l Upgrade ( ) Abandon ( ) an individual sewage disposal system
at ac) as described in the application for
Disposal System Construction Permit No. ate
6
Provided: Construction shall be completed within 4Ue/,yi V ars.of the date of this permii\tt... All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date/2 D ' " Board of Health