HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6WIX48 FEE
,�v�lam,
alth,
/ Board of Hect r �i� t� MA. APPLICATION FOR ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT
IAl? lication for a Permit to Construct( ) Repair
Abandon( - ❑Complete System ndividual Components
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cation Owner's Name e
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ap/Parcel# �j
Address
Lot#
Telephone# — F_ 75 = �'S�S✓`
Installer's Name
Designer's Name
Address 3
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Address �<
Telephone#
7 _
Telephone# � e 36-:0 — s
Type of Building b �z``y'�'�� ��//�� Lot Size 2Q, G'c2,!t7 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3Q gpd Calculated design flow Design flow provided ^��g gpd
Plan: Date Number of sheets % Revision Date
Title ,�/ i�/� `7 -S, fd
Description ofSoil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS GlSe
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed .�, Date ts`/11�11.ell
Inspections
k-/00
Board of Health, �`��' ��` MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 6Individual Component(s) ❑ Complete �6System;,/ 5 �(
The undersigned hereby certify that thg Sewage Disposal System; Constructed ( ); Repaired (, , Upgraded ( ), Abandoned ( )
by:
has been installed IiAaccordarice with the provisi os o 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated — Approved Design Flow (gpd) c
Installer �' �'`" c —.-= �_.. k fd " t�
3— -ry
Designer:
g U Ua t� CjA p e Inspector: Date:
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
No. �-4-DC "' �" �tCA-PE COD FEE J U�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �cr-��' au MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(Upgrade( ) Abandon ( ) an individual sewage disposal system
at S v i r �- r as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed 'within thrggthe date of t p rmit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date t + rr� r�ifBoard of Health �of