HomeMy WebLinkAboutApp-Permit-Compliance'No. 0 7-(y FEE.
VB:RMOUTH HEALTH DEPT.
Board of Health, J MA.
�ReUTE 2-9
APPLICATION FOR DISPO 1� M, M"l UCTI®N PERMIT �
Application for a Permit to Construct( ) Repair( ) Upgrade`(/) Abandon( ) - ❑ Complete System Nndividual Components
Location 52Z
Owner's Name
Address
Map/Parcel# , 7
Lot#
Telephone#
Installer's Name
Designer's Name
Address ��' f
aap
Addresslee
Telephone#
Telephone#
, 34 --;k- •— qA;1—
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms -2 Garbage grinder( )
T—
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) 6�L+ a�
Soil Evaluator Form No. Name of Soil Evaluator 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 a es to not to place the system in opera ' until a Certificate of Compliance has been issued by the Board of Health.
Signed Date c d
Inspections
No. d 7 COMMONWEALTH
MASSACHUSETTS
Board of Health, MA.
TIFICAff OF COMPLIANCE
Description of Work Individual Components omplete System
FEE
74�1 b
The undersigned hereby cer at t e Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (PI, Abandoned ( )
by:
at
has been installed in accordance with the rovisions of CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.. , dated . Approved Design Flow!%a% (gpd)
Installer
Designer: G6 4.4&!%n
The issuance of tthiis permit shall not
No. 0 ! �x
Inspector:
Date:
e construed as a guarantee that the system will function as designed.
Board of Health, MA.
DISPOSAL SYSTIA CONSTRUCTION PERMIT
FEE � U �'
W-P1 7
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(i-y Abandon( ) an individual sewage disposal system
at / & /(JA .e"k-, , p / Jf44n�2A / as described in the application for
j
Disposal System Construction Permit No. 6768'd ated �"� 7
(p I Yw S
Provided: Construction shall be completed within thTie s of the date of this er ' . /All iti
y local condons must be met.
Form 1255 Re 5/96 A.M. �ulkin Co. Boston, MA Date �1 hoard of Health L/