HomeMy WebLinkAboutApp-Permit-ComplianceNo. �C``u Mex- FEE (V�
r COMMONWEALTH Of MASSACHUSET BLS J I Z5 J
Board of Health, yFwColi�� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairW Upgrade( ) Abandon( ) ❑ Complete System QI Individual Components
Location (00
Owner's Name CK. n VS
Map/Parcel#
2 2 r 3 D / C( Z 9
Address (Bo VA-Vlgn %A
Lot#
Telephone#
Installer's Name
Designer's Name
Address
t i .., c : dl
Address
Telephone#
S. q Lk-1T59 'j')
Telephone#
Type of Building u✓1 O Lot Size (00� 0400 sq. £t.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ).
Other Fixtures
Design Flow (min, required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No
Name of Soil Evaluator
Design flow provided gpd
Revision Date
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 ton place a system in operation until a Certificate of Compliance has been issued by the. Board of Health.
Signed Date I O
COMMONWEALTH OF MASSACHUSETTS
Board of Health, � (/ J , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired 6(f Upgraded( ), Abandoned ( )
j"
has been installed in accorda e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated /1) --//o Approved'Design Flow (gpd).
Installer
Designers - "` Inspector: —'o ,r u , 0, Dater a
The issuance of this permit shall not be construed as a, guarantee that the system will function as designed.
No. 90AID`' U���✓ �. �� �r _ FEE
-�. COMMONWEALTH Of MASSACHUSETTS
Board of Health, NUN NJ ! fit' M.A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade(
) Abandon( ) an individual, sewage disposal system
as described in the application for
Disposal System Construction Permit No. d , dated
Provided: Construction shall be completed within three years of the date of this permit All local Vc9d,`,'ns must be met.
f j3 � � J; �
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date % ! /Board of Health