HomeMy WebLinkAboutApp-Permit-Compliance114E RV ILI E 23
Cn liAiI!'+foOUTH, MA 02664
C®MMONTTALT14 OF MASSAC14USETTS
Board of Health,
AL4.
FEE e � a�
vjc� 10,90
APPLICATION FOP, DISPOSAL SYSTEM'][ CONSTRUCTION PERMIT
Application for a Permit to Constructje�Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location L Dof V
Owner's Name G(�
Map/Parcel#
Address
Lot# A C!
Telephone# ^��
Installer's Name
Designer's Name
Address C PJ
Address A
tMORP
Telephone#
Telephone#
Type of Building rN Lot Size * sq. ft.
Dwelling - No. of Bedrooms Garbage grinder M
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design/ flow Design flow provided — gpd
Plan: Date Num�ber of sheets / Revision Date
Title / ^t l>! /'e t,%p
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 the provisions of TITLE 5 and
farigned ther a ees not to ace system in o e don un a Certificate of C plia4ce has been issued by the Board of Health.
Signed i 6I Date
Inspections
J.
p. __..
No. -/ ! y-,)- 5 FEE
Board of Health, MA. ' y'
CERTIEICAT ®E COMPLIANCE
Description of Work: ❑ Individual Component(s) CAomplete System
The undersigned hereby certify that the Sewagf Disppsal System; "Constructed�Repaired ( ), Upgraded ( ), Abandoned
at 1P
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _-5;" 7 -�2t 4 , dated %Z 1 _y Approved Design Flow 39& (gpd)
Installer G{ ' t
Designer: �Qw _ Inspector: Date:
The issuance -of this permit shall not be construed as a guarantee that the syste wiliflinction as designed.