HomeMy WebLinkAboutApp-Permit-ComplianceF�4Z2-.
No.
�'el FEE l
® COMMONWEALTH Of MASSACHUSETTS
Board of Health, yl X td ; MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair{ � Upgrade( ) Abandon( ) - ❑ Complete System 06,11 dividual Components
Location �Q,
Owner's Name s5 � At ,&t
Map/Parcel# � (�� �
. AJ . &,
Address 3'�% �l,.G�jtJ d/�
Lot#
Telephone#
Installer's Name ��
Designer's Name
Address 3/i✓- ^
Address
Telephone# b��
Telephone#
Type of Building ,� J 2_ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder,�a
'c3 % No. of persons Showers
Other -Type of Building _ p . � O ,Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evahaator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned a to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees do p e th to at' n until a Certificate of Compliance has been issued by the Board of Health..
Signed
Inspections
No. 7�" L/�"["' 1�_ FEE✓,.(
COMMONWEALT14 OF MASSACHUSETTS
f, , dV:3
Board of Health, 0� Md. r- .
CERTIFICATE Of COMPLIANCE
Desr>tption of Work: ✓� Individual Component(s) ❑Complete System/��%%�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired , Up raded ), A andoned O`
at ?1,2.
has been installed in accordance with the provisions of 310. 15.00 (Title 5) and the approved design plans/as.-built plans relating to
application No. `X _`
dated ��,.---�—��. Approved Design Flow—' (gpd)
Installer s ; ^ + rr ", "r S,
eA axDesigner: Inspector: Date:
The issuance of this permit shall not be ;construed as a guarantee that the system will function as designed. ;
No. Jbc o SD C 't �G Zz, FEE_
115, 06
COMMONWFALT14 Of MASSACHUSETTS
Board .of Healtla,7 O t� i�� MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair (fir' Upgrade ( ) Abandon( ) an individual sewage disposal system
at 2r' / vn� Z2r' � _ � '� +� ✓ as described in the application for
Disposal System Construction Permit No,d dated
l
Provided: Construction shall be completed within three years of the date of this p mit. All local cn 'tions must be met.
Form 1255. Rev: 5/96 A.M. Sulkin Co. ChaiiesloWn, MA Date2_ Board Of Health