HomeMy WebLinkAboutApp-Permit-ComplianceNot•-/ 7 s ; s � FEE
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COMMONWEALTH Of MASSAC14US ETTS
Board of Health, , MA.
APPLICATION FOR ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System VIndividual Components
Location Vt C.k Qrs,0Aj
Owner's Name CkaQknia
Map/Parcel#
Address �'t� C �Qr o
Lot#
Telephone# '-� '9"6—L 4
Installer's Name /^K° k L�� ±
Designer's Name
Address f h ��
Address
Telephone#
Telephone#
Type of Building �& tt C-(,N� ` 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) gpd Calculated design flow Design flow provided
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tp n to pl a system in operation until a Certificate
//of Compliance has been issued by the Board of Health.
Signed Date /�z
Inspections
No. / FEE
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 051ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at L° ' t C—
e
has been installed in accord an e with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ^ / "� dated C.�> -- /` �� Approved Design Flow (gpd)
Installer -AA 1 1,C (9 L_ (5i, Gl _ V LZ �
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Designer: / l.I/� Inspector: ' te: f=
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.