HomeMy WebLinkAboutApp-Permit-ComplianceNo. $014)C — te-4q3Z FEE ` 5i7eO
COMMONWEALT14 OF MASSACHUSETTS duknai
Board of Health, -1/ MA.^
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Q/ll_u/pgrade( ) Abandon( ) - ZComplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# j
Address?,6r,;-_,.k-
Lot#
Telephone#
Installer's Name
iwl
Designer's Name
Address �.`_o u�ia si. r<.svu �
Address/2 ��i f C�Ofr�ic/ X . •r�P'
Telephone# _r ��7
7-1—_ �Z r
Telephone#
Type of Building Lot Size -" sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 O gpd Calculated design flow Design flow provided 3 !9c . 7 gpd
Plan: Dates l/� i �t� Number of sheets 1;;Z Revision Date
Title /gi"'L a -4 -P'
Description of Soil (s) _
Soil Evaluator Form No.
-1 I'll
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
1a
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nQLto place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -�--� Date
' Inspections
No. t✓ k YC. r b� FEEE'd� S a Q
COMMONWEALTH OF MASSACHUSETTS CW -Z-Y75
Board of Health, LF'o `�. av�� MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Components) ,'�1'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (%graded ( ), Abandoned (
by:at C�f e��
has been installed i cc1 e with the provisions of CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.'/ dated Approved Design Flow �pd)
Installer
Designer: hiG l h J �—� 1 N ' ,� t��` Inspector: 4f!!:�(S, ` � Date:
The issuance of this permit shall not be construed as a g.,m tee that the system will function as designed.
No. I N T)C C4(2CC fj�(> _5 C_ 514C13 FEE
COMMONWEALTH Of MASSACHUSETTS Ck4 Z d, /'I
Board of Health, MA.
DI[SPOSA]L SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair (grade ( ) Abandon( ) an individual sewage disposal system
at r, ? f .'� as described in the application for
Disposal System Construction Permit No..dated 7 �d-ated d
Provided: Construction shall be completed within e. ears of the date of this pelt ',Ali local condom 'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date l 16 / Board of Health Uf G/