HomeMy WebLinkAboutApp-Permit-ComplianceNo. P,;0 "-DC- [8-6685—
&_P"✓ — l y' a®(J9� FEE' �W y
X_/'7z___ COMMONWEALTH Of MASSACHUSETTS C 1! t S 1-0
Board of Health, Y!mm elk TQ , MA.
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( ) _ Complete System ❑ Individual Components
Location6ULZ"AAete_=Owner's
Name
Map/Parcel# ell
Address c
Lot#
Telephone#
Installer's Name 9�
Designer's, Name
Address�k`� l Q
Address
Telephone# �� el
Telephone*
Type of Building 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) 330 gpd Calculated design flow Design flow provided gPd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
4
DESCRIPTION OF REPAIRS OR ALTERATIONS _G
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the, provisions of TITLE 5 and
further a ees to not to place the system in opera 'on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date %! 3 ell P'
Inspections
No. C -.'.' (�a
COMMONWEALTH LTH OF .l` ASSAC14USETTS FEE t
Board of H alth, )Lng&Q 1 n--}+
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) pld(�)uxplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( <graded Abandoned
at
has been installed in accordance with the provisions o K0 CMR 6.00 (Title 5) and the approved design plazas/as-built plans relating to
application No. , dated -7 Approved Design Fl w (gpd)
Installer C 4 1 —e7 �
_ Designer: ` // Inspector:. Date:
The issuance of 4 uspermit shall not be construed as a guarantee that th sys em will function as designed.
No. li C''►131 `6095 FEE �
COMMONWEALTH Of MASSACHUSETTS
Board of Health, t
JAM t)(M+ MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrad 4
Abandon( ) an indixidual,sewage disposal sy4rn
at ` f' p _ (� _,as described in the. application for
Disposal System Construction" Permit No. �1 , dated��.
Provided: Construction shall be completed within t4ehe date of this r :nit. All loca con itions must be met.
C^� Form 1255 Rev. 5l96 A.M. Sulkin Co: CWestown, MA Date ! Board of Health