HomeMy WebLinkAboutApp-Permit-ComplianceNo. ®6 A FEE
/,,,/OMMONWEALT14 Of MASSACHUSETTS
I Board of Health, T" MA.
% ]C CATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
�or�S
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon() - CXomplete System ❑ Individual Components
Location .k
Owner's Name 45
Map/Parcel#
Address
Lot# 1
Telephone# `
Installer's Name `� uL
Designer's Na 5\-) y J
Address
Address -� y
Telephone# co gig,.�
Telep
one# _719Q ZS?
Type of Building
6ecT6 Lot Size "[ ()( sq. ft.
Dwelling - No. of Bedrooms
�J Garbage grinder (Iq f A-
Other -Type of Building
Wewlve No. of persons Z Showers ([0Cafeteria (%4�
Other Fixtures
Design Flow (min. required)
gp Ca culated esign flow �b Design flow provided 3 gpd
Plan: Date �. �� - b�D
N mber f shee s Revision Date
Title .
Description of,Soil (s)
Soil Evaluator Form No.
ame of Soil Evaluator C�crosn n S�k>� Date of Evaluation ��- S-05
DESCRIPTION OF REPAIRS O
RATIONS c
The undersigned a e to install the ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no. lac
in peration until a Certificate of Compliance has been issued by the Board of Health.
Signed
Date 177
Inspections
t/ `l
-- — -- — — — -- FEE
No.
COMMONWEA LTH Of MASSAC14USETTS
Health, MA. G "`
Board
of ,
CERTIFICA OF COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersign e r by certify
that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( Abandoned ( )
by: —
t
at
`ti N r .
has been installed in ccor
e with the rovi ions o 310 CMR 15.00 (Title 5) and td, a roved design plans/as-built plans relating to
-
application No.
ated Approved Desi n low (gpd). /
&
Installer
,
Designer:
Inspector: Date:
The issuance of this p •mit shall not be construed as a guarantee that the system will function as designed.
No.
FEE
"�
COMMON
Board of Health, A r MA. ((�i
DISPOSAL SYSTA CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade Abandon ( ) an individual sewage disposal system
at t /1 I r_
6 A, `Soft , / (A ,s Wto � �' � as described in the application for
Disposal System Construction Permit No. �(0 �, dateh O "
Provided: Construction shall be completed within ___t6*s of the date of this p� it. - l local conditio s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston,,MA Date �L �� Board of Health /