HomeMy WebLinkAboutApp-Permit-ComplianceNo. 00C- KL — V FEE'
1 COMM06 LTIJ Of MASSAC USETTS C *-12, 3
Board of health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application fora Permit to Construct( ) Repair{jk Upgrade( ) Abandon( ❑ Complete System Wndividual Components
Location
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Owner's Name �� oo �o✓t sJt of
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name ✓7-e
Designer's Name
Address
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W tM �1n�IrL +yl
Address
Telephone#
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Telephone#
Type of Building 0"i J Lot Size b 0 Ooa '}- sq. ft.
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 Design flow provided gpd
Plant Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS-e- Z-6 1� t3 O
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with theprovisions of TITLE 5 and
further agrees to not to place the stem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No: r�✓d��G"'!G� f✓�� 'fi• /!r? d/'Pr'FEE !ut(/V
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C®MMONWEALTI-I OF MASSACUUSMTT
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ()�', Upgraded ( ), Abandoned ( )
at
has been installed ii accordance with the proviskons of,Sl(1 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. I dated 1 % ��� Approved Design Flow (gpd)
Installer r 1�. , '14� i tie 5
Designer: Inspector:. Date: _ �1&j o
The issuance of this permit shall not be construed as a, guarantee that tl& system will function as designed.
No. CAP C— FEE 5 j
COMMONVVEALT14 OF MASSACIIUSETTS Z-9 3
Board of Health, y-A3z 0yMj , M.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(L. Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within three years of the date of this per nit. All local col7ditions must be met.
Form 1255 Rev: 5/96 A.M. Sulkin Co: Chade5lown, Ma Date Board of Healthrf
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