HomeMy WebLinkAboutApp-Permit-ComplianceNo.� f FEE 5v-
COMMONWEALTH
5yCOMM®NLTH Of MASSACHUSETTS
Board of Health, YAQMO,UTH HEALTH DS'.
APPLICATION FOP, DISPOgk%=, �Q��UCTION PERMIT
Application for a Permit to Construct( ) Repair() Upgrade (:�Abandon( ) - ❑ Complete System ❑ Individual Components
Location
tZ J/ J4je�& 44--f_jF-
Owner's Name
Map/Parcel#
Address p tue
Lot#
Telephone#
Installer's Nam�(�
(�
Designer's Name 6c- W66 -
6 -Address
Address
f44 �--
Address clookS aW
Telephone#
t
Telephone#
Type of Building 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) q3a — gpd Calculated design flow � Design flow provided gpd
Plan: Date Number of sheets ,D� Revision Date
Title �Z
Description of Soils) -e7e s oi Ir
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS U12 6A4D'_ &m
The undersigned agrees to ' stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further est not to pl the system in operation until a Certificate of Co//mplianpe has been issued by the Board of Health.
Signed Date C-7
°Inspections
No. � � w �y FEE
COMMONWEALT14 OF MASSACHUSETTS
ZZ
36
Board of Health, YAa, MA. �l��G
CKPITIFI
E Of COMPLIANCE
Description of Work: ❑ Individual Component(s) l !Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (graded (., ), Abandoned ( )
by: O APE' �,*LIA4 t x
at VAVW
has been installed in acco dance withthe !ovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �l 7� '�5 dated `i��o' �� Approved Design Flow (gpd)
Installei�c/ V 6,Z A-V A / i �' Y A "o i, ; I
Designer-3-ar F%n 0 Inspector: V < V 64"4469W Date: �.
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. o` 2.�
COMMONWEALTH OF MASSAC14USETTS
Board of Health, 4-Mnm 0 u MA.
DISPOSAL SYSHM CONSTRUCTION PERMIT
Permission is
at ),!�' A
FEE / -!
C. � r -t i� &I I
by granted to; Construct( ) Repair( ) Upgrade( Abandon ( ) an individual sewage disposal system
-G��s � atirS
� 2 as described in the application for
Disposal System Cor{struction Permit No. p h� >, dated 7 2 3 O/
6�0v ,•
Provided: Construction shall be completed within ears of the date of this per it. All local conditions must be met.
Farm 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 7 t-)./�
5y UBoard of Health