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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �ofl�Dc��-O L' LD nz —l6-:-6o I S3S COMMONWEALTH OF MASSACIIUSETTS Board of Health, L Ik(LN10 , MA. A )C APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE �rl or) C3► % Application for a Permit to Construct( ) Repair() Upgrade N 11 Abandon() - ❑ Complete System y4ndividuaI Components r Location 14ff g(L Owner's Name rv/ ' Vol Map/Parcel# b Address Lot# Telephone# 7- 10 Installer's Name Designer's Name S Address `& t7 Address l Telephone# Telephone# Type of Building Lot Size >%u/'f Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures 2 Design Flow (min. required) 3 3 t) 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 DESCRIPTION OF REPAIRS OR ALTERATIONS Date of Evaluation The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t vA lac system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. C� if A� T ©y FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, CERTIFICATE Of COMPLIANCE ak Description of Work: Individual Component(s) ❑ Complete System 1� The undersigned he)repy certify li z the Sewage Disposal System; Constructed ( ), Repaired ( , Upgraded ( ), Abandoned ( ) by: at has been installed in a/cIrdalicAilth` the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application NcO *>l -?I -,��/,-ated &2 R - N Approved Design Flow � S � (gpd) Installer Designer: -/% `-6i' P Inspector: 1 VA Date The issuance of this permit shall not be con trued as a guarantee that the system will function as designed Z- COMMONWEALT14 Of MASSAC14USETIS Board of Health, MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) at i/ 7 Il tilr /S ( IQO,�-l O//G/f FEE O C) Repair( `/) Upgrade( ) Abandon( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit NoYO -/ - /dated 1 -/ Provided: Construction shall be completed within *ham -ter crate of this permit. All local conditions must be met. �a - /� Form 1255 Rev. 5/96 A.M. Sulkin Co. Chatleslavn, MA Date Board of Health ..�%