HomeMy WebLinkAboutApp-Permit-ComplianceNo. i o%Dc—(8—otn FEE Sj55,
Board of Health, MA.�
APPLICATION FOR DISPOSAL SYSTEM CONSTRU;,,jI0y IT/
Application for a Permit to Construct( ) Repair Upgrade Abandon O Complete System ❑An1�,i4 Components
Location
Owner's Name�(�j,G o `�
Map/Parcel# �,2� !�� �'
Address Sa��
Lot#
Telephone# T��
Installer's Nam l ��-",ee%s
-%e S
Designer's Name
6 tci id r pro `
Address s�
Address
Telephone# o _ -� _ 2
Telephone#
Type of Building—LLot Size V* aoo sq. ft.
Dwelling - No. of Bedrooms 7r Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 7 71:57 gpd Calculated design flow Design flow provided 7 7z gpd
Plan: Date Number of sheets Revision Date
Title i'iki� , 5--
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR
i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees ton t to place the system ' ati until a Certificate of Compliance has been issued by the Board of Health.
Signed' Date z/,r
Inspections
r`A /&
No. �/ C + u a i I / FEE .
` NIA. ok
Board. of Health, � 1/� <-. _�.��.. �/ � � � 8
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ,'Complete System (,�{ YO,;/A�andoned
The undersigned hereby certify that t e Sewage Disposal System; Constructed( ),Repaired(, UUpgra( )
by:
at /d'r' �7r 15"•� ircl f o• r��..,Cs� /�'Q �`�
has been installed 'p acccoordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. -'G' dated l_ Approved Design Flow 77-R (gpd)
Installer
r
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guar tee that the system will, function as designed.
No. 4-�� �"'� C7�tJ��� l oD SC'se�VI�� FEE
COMMON'W,, Z-5�g
r
Board of Health;'�cr..-air, MA.
DISPOSAL SYSTEM CONSTRVCTI®N PERMIT
Permission is herebyranted to; Construct Repair 4,�U rade e �/A�bandon an individual sewage disposal system
g O P i `7 pg .-i vl O g P Y
i
at "/ 0;7¢-
Disposal System Construction Permit No. dated.
_ as described in the application :for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 A.M. Sulkin Co. Boston, MA Dateg` t� Board of Health