HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13() ,4j) — 117-6-3?7
FEE
Board of Health, �41 Y,/Vl a ✓ MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(bandon( ) - lT Complete System ❑ Individual Components
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LocationAIALa
Owner's Name
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Map/Parcel#
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Address
Lot#
Telephone#
060.�
Installer's Name
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Designer's Name
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Address
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AddressW
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Telephone#
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Telephone#
90 3 - - 2 8 15
Type of Building /C
Dwelling - No. of Bedrooms
Other - Type of Building _
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Lot Size Ego ,, sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ZZO gpd Calculated design flow 3VI 9 P61� Design flow provided 3 gpd
Plan:
Title
Desci
Soil I
DESCRIPTION OF REPAIRS OR
. ;,
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t%% not to place die system in operation'until a Certificate of C mp 'ance has been issued by the Board of Health.
Signed Date
I"
Inspections
No: t"r C " 1 �7 �/� FEE 00
C®�9[�9 ONWEALT14 Of MASSACII�J TT
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Board of Health, t A /io 6 P "L MA. Ar
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) a -complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (I �,Abandoned ( )
by: 1111k1,'1 L i. C SE�. .
has been installed ' r.accory�iae with the/prov'siioons of NO CMR 15.00 (Title 5) and th roved design plans/as-built plans relating to
application No.: d / (J , dated PO / d Approved De gn Flow _ (gpd)
Installer M � 'J( Q t (,,�
Designer: Inspector: Date:.
e of this permit shall not be construed as a guarantee that the system will function as designed.
e issuance
No. Ss o kyjoi A( t. (A ty j � �' a � C-T r ll `C—
le COMMONWEALTH Of MASSAC14USETTS
Board of Health, iCr ✓ MA.
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FEE
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DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) , Upgrade (V) Abandon ( ) an individual sewage disposal system
at / 31 A (-/i
as described in the application for
Disposal System Construction Permit No. `� %J , dated
S
Provided: Construction shall be completed within t—s of the date of this perm t�, All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston,
MA % Date (� �r' Board of Health /