HomeMy WebLinkAboutApp-Permit-ComplianceA�
N,. 1304W_( —2-50 Vub TV, -I —005-3 2-3 FEE:
lf_J�5_7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, y/�'6tf1-,1' , MA.
T00%4 �lee
APPLICATION FOR DISPOSAL S STS[ CONSTRUCTION ftRMIT / !/�
plication for a Permit to Construct( ) Repair( Upgrade Abandon( `omplete System 0 Individual Components
Location
1.Map/Parcel#
Owner's Name
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address a.
Address
Telephone# - *'Z
Telephone#
Type of BuildingLot Size
Dwelling- No. of Bedrooms Garbage grinder
Other -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. reuire) gpd Calculated design flow Design flow provide gpd
Plan:' bate.___3 f of Number of sheets 1 Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage.Disposal System in:accordance with the provisions. of TITLE 5 and
further agree o plac em in operation until a Certificate of ompliai�ce has been issued by the Board of Health.
Signed. Date
J
Inspections.
No.. FEE
COMMONWEALTH Of MASSACHUSETTS cft- -7 0 Lj
Board o f Health, YAM OU7 4 , M.A.
�v
CERTIFICATE Of COMPI.IA'NCE ,
Description of Work: .0 Individual Components) ❑ Complete System
The under' tied her* certify that the Sewage Disposal System; Constructed ( ).,.Repa reX Upgraded( ), Abandoned O
by:CL
at r
7C
has been installed in accordance with th fo�i 10 CMR 15.00 (Title 5) a ddt e ap�� Oved; design plans/as-built plans relating to
application, No. /p dated, Approved Design Flow r (gpd)
Installer
The issuance of this permit shall not be construed as a guarantee that the system. will function as designed.
7 COMMONWEALTH or, MASSACHUSETTS
Board of Health, ,QV MA.
DISPOSAL, SYSTEM CONSTRUCTION
Permission is hereby guanted to; Cc struct(
d C_ e-1/ "? _)N
FEE -
Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal' System Constt uc.tion Permit No. - /dated -,7-
^.
.- � 1
Provided: Construction shall be completed withi ars ofZ date of this permit, AU local co.nditio s must be met.
Form 1255 Rev. 5/98 A.M. Sulkin Co. Chadestown, MA Date : oard of Health
r%'