HomeMy WebLinkAboutApp-Permit-ComplianceNo. Dcoc l_'IS I - � �. J FEE
COMMONWEALTH OF MASSAC14 SETTS C"410 1
Board of health, )LA -R 101�-�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon(;lom Tete System O Individual Components
Location ��% r
Owner's Name ' C
Map/Parcel#e
Address ,3f
Lot#
Telephone#�
Installer's Name
Designer's Name S
Address d
Address "
Telephone#
Telephone#
Type of Building Lot Size Zi� 4� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( j
Other - Type of Building No. of persons Showers( ), 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) �y���►'0
Soil L'valuator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further aimees to not to place the system, in operati mils Certificate of Compliance has been issued by the Board of Health.
Signed .,��_���j�C�A Date r� _
No. EE
COMMONWEALTH OF MASSACHUSETi�
Board of Health,yAg:mO dyk ' l
CERTIFICATE Of COMPLIANCE ° _#'/�
Description of Work: ❑ Individual Component(s) Ul omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( , 5andoned
by: ( }
u _
at
e >.
has been installed in accordant. the ovisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. - " r dated - Approved Design Flow (gpd)
Installer i .41 .n, <Y _4.7% ,ter .4 Z6 _r . s`7�" Lf�,: /,V o � 1/ i{ �
Designer: 7 �Q��a�.� �( Inspector:_ s 1_ Date:
The issuance of this permit shall not be co grued as a guar . ee that the system will function as designed.
No. � 6`i "}t ��! C5-C_'r !(n l � FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �1�1 �3 l jamMA.
DISPOSAL SYSTEMCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (abandon ( ) an indh dual sewage disposal system
at t G; _-- as described in the application for
Disposal System Construction Vermit No. I 115P-,), dated
Provided: Construction shall be completed within t ofe date of this permit. All local conditions must be met.
i
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date�/-5�Board of :Health k/Au