HomeMy WebLinkAboutApp-Permit-ComplianceNo'
COMMONWEALTH OF MASSACHUSETTS
FEE'
03g5a-
Board of Health, �f Q�(��l��i MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repaird Upgrade( ) Abandon( - ❑ Complete System Z7-If vidual Components
Location
Owner's Name -e ( , 0,
Map/Parcel# 5 %
Address
Lot#
Telephone#
Installer's Name Y
Designer's Name
Address-P \
Address _
Telephone# '1"1
Telephone#
Type of Building vxtA Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria,( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONSi�Gt�-�`V�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to place the system in operation until a Certificate of Compliance h been issued by the Board of Health.
Signed OeA011 Date q
Inspections
• .. -. - -. - _ . r
No. 60� � t1 6 1-17 1.J ;,�. t. FEE
COMMONWEALTH Off' MASSAC USETTS
Board of Health, Aam o 4 , MA.
CERTIFICATE OF,, COMPILIANCK--,
Description of Worka�"Individual Components) ❑Complete System P&6),
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaire UpgrAbandoned
by
at
has been installed i1 accordance with the rovisi ns ooffj/,/3`A'r,11.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `�J �°6 ,dated. Approved Design Flow '"""�' (gpd)
Installer NO c l -i i
Designer: ""` Inspector: = .1� ;n_W_c Date:
The issuance of this permit shall not be construed as a guarantee that t e system will function as designed.
No. 13 ®t'T��-. I' L /1 F-�-' �c- rC FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �tW1111 i�%� MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repai r)Upgrade( ) Abandon( ) an individual sewage disposal system
at I U
�as described in. the application for
Disposal System Construction Permit N C/ , dated 67 r
Provided: Construction shall be completed withw t- a f e date of this permit. All local conditions _must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date of r f Board of Health .'