HomeMy WebLinkAboutApp-Permit-ComplianceNo.a-3'��
FEE J `-'
n r j C®MMONWEALT14 OF MASSACHUS ETTS
j) p rBoard of Health, MA.
(- I �,I�A ip 4,4 --f
APPLICATION FOP, DISJ fllEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( }. U 1J'W itdon() - ❑ Complete System ❑ Individual Components
Location 60S�
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name A4„ % C.^C
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS L>, . L - �. , � ��� �—
The undersi in ed a es to stall the above described. Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a s to place the system in operation until a Certificate of Compliarice has been issued by the Board of Health.
Signed Date ll l
Ins /ctions
No. d [ i " ),r- lvi FEE J "
C®MM®NWLA.LT14,. ®F ASSAC14liSETTS
Board of Heahh.
RT ICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s ❑ Complete System
The undersigned hereby certify that the Sewage isposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( )
by: �Z, Co. r, C.0
at Sc7
has been installed in accorrclance with the provisio s of 310 CMR 15.00 (Title b) and the approved design plans/as-built plans relating to
application No. Q? - 3 "D dated l 1 3 07 . Approved Design Flow (gpd)
installer,,
Designer: Inspector:, ' Date: t i✓
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE
COMMONWEALTH OF MASSAC14USETTS
r
Board of Health, ��R ✓ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at So �Zj as described in the application for
Disposal System Construction Permit No. 0-7 , dated t I I - l U
Provided: Construction shall be completed within three years of the date of this per it. All loc conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date l t ! 3�U7 Board of Health