HomeMy WebLinkAboutApp-Permit-ComplianceNo. + F ✓ L� �{ �V V 4 FEE 0
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair.( ) Upgraded Abandon( - ❑ Complete System Qjaual Components
Location �(
Owner's Name DO E
Q`�
Map/Parcel# 5 2 C✓
Address In
Lot#
Telephone#
Iristaller's Name c
Designer's Name
win
Address I
Address a
Telephone# V g 3 .- `j
Telephone# W6- L
Type of Building 1 l �1
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date S ' - 1 -2
Title
Description of Soil(s)
Soil Evaluator Form No. ,
Lot Size��� sq. ft.
Garbage grinder {
Showers( ), Cafeteria (
Number of sheets Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation �1;�
opoll n A p &j S4:r= M
gpd
The ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furtherVaest n pl a stem in pera ''°A until a Certificate of Compliance has been issued by the Board of Health:
Signed ���. ate
r
Inspections
No. �;�� "r� �.��'-� " �+� 'l:®MMO W LTR'l F M1-1tSSACHUSET S
loll 1-71
Board of Health, ,
CERTIFICATE OF COMPLIANCE
FEE S
5 Utz
Description of Work: Individual Component(s) O Complete System I
The unders' n d hereby certify that die Sewa e'Disposal System; Constructed O,Repaired ( ), Upgraded (Audo d ( )
at i' .r
Al i2t"
has been installed ii accordance with the rovisions of 0 CMR 15.00 (Title 5) and the oved design plans/as-built plans relating to
application No. 7 ?� , dated. Approved Design Flow _-� �(gPd)
Installer i..'
Designer: w-.Inspector:r
Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (i ►fr^� FEE
71 COMMONWEALTH Of MASSACHUSETTS
Board of Health, gmo1m+
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Abandon ( ) an indix idual sewage disposal system
at _: 0.) as described in the application for
l �
Disposal System Construction Permit No. / % , dated 7
Provided: Construction shall be completed within three years of the date of this per xy"ttll local condi ' t� S must be met.
Farm 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date T (,Board of Health ,�