HomeMy WebLinkAboutApp-Permit-ComplianceNo. O WD C 0 q`S— FEE W 53" W
Board of Health, .vim MA. b ice"
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (ol4pgrade( ) Abandon( ) - ❑ Complete System Y� _I vidual Components
Location bu�(
Owner's Name ea
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Map/Parcel#
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Address U
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Lot#
Telephone#
Installer's Name M C
Designer's Name
Address '�
yl a E 1�toaton�TTIphne#
Address IZA7—
Telephone#
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Type of Building �ll�s✓/��,�rf.-,w Lot Size % sq. ft.
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Dwelling - No. of Bedrooms 2= Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 2 -2 gpd Calculated design flow Design flow provided �-2 o gpd
Plan: Date ////6�Number of sheets Revision Date
Title ; X
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _w /� /30,� P/i y PYi� /i`'✓� cry
The undersigned undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed�'6 �P Date /z�iz�i.rr
Inspections
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FEE QO
Board of Health, MA. 6
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CERTIFICATE Of COMPLIANCE
Description of Work: Wax ividual Component(s) ❑ Complete System 6/ ',)(
The undersigned hereby certify that e Sewage Disposal System; Constructed O, Repairedd- 4up'graded ( ), Abandoned ( )
at ,
has been installed �acc0 da e with the p ovisi u}s of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No �/ dated �6 r Approved Design Flow
Installer
Designer: 1214,41,f l L '-Thspector: J ;o -` . f is-0 AtV Date: T 1 ! 7
The issuance of this permit staff not be construed as a guarantee that to system will function as designed.
No. .�, 0 J .� CAP( CC `J��'r�l �. �VC,� FEE ` l��}
�4" COMMONWEALTH Of �'1 ASSAC14USETTS �� � p ��
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairk_ ' Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed withw_tk e� the date of this permit. All local co Pons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date .-1 /4Oard of Health !