HomeMy WebLinkAboutApp-Permit-ComplianceFEE 5 A
CO MONW LT Of MASSAC14USETTS oo �� o q
Board of Health, Mtl. JUN 18 2018
APPLICATION FOR DISPOSAL SYSTEMCONSTRUCTION P RM<H DEPT.
Application for a Permit to Construct( ) Repair(.) Upgrade andouO - ❑ Complete SystemIndividual CompWI /,7
Location �
Owner's Name et V Oit1"K (_
Map/Parcel# c— `4 6 (c7
Address /
Lot#
Telephone# Q 73 — 75 7 — %,� >
Installer's NameDesigner's
I
Desi ner�'sN�Y / �/4C_S Op
Address
.asmeGl(�
OCwa
Address �
Telephone# 77 D6S 3
Telephone#
Type of Building E -J ( Lot Size sq. ft.
Dwelling - No. ,of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min, r quir(Ir
) , 33 U gpd Calculated design flow Design flow provided' gpd
Plan: Date t0 �z D Number of sheets / Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS _ 142 -0d, -box. (z) 7V 2 C) s
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees of to place thetem ' o tion until a Certificate of Compl'ali has been issued by the Board of Health.
Signed Date L �Zgl
Inspections
No. t f/ " 1 '- (� 'i� FEN
COMMONWEAA OF MASSACHUSETTS if
II
Y Board of Health, f 1 �1 -' L4 "` , MA.
CERTIFIC TE Of COMPLIANCE
Description of Work; C• 46dividual Component(s), ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System Constructed O, Repaired ( ), Upgraded Abandoned(
by: CeLl
at 1, r i earl p V Ct(1Y)U�. _
has been installed ii accordpjce with the provisions 0 CMR 15.00 (Title 5) and th roved design plans/as-built plans relating to
application No. +t� dated " % Approved Design Flow 7 (gpd)
Installer �� C /
g p__
Designer: � Ir� t � l �y Inspector: r2LI;Date: s
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
FEEvi, a�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, l TI r )1 J T" , MA.
DISPOSAL SYSTE CONSTRUCTION'- PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( Abandon( ) an indilidual,sewage disposal system
at AN / as described in the application for
Disposal System Construction Permit No.4, dated:
Provided: Construction shall be completed
�jwithin
y three years of the date of this p rmt. All local conditions must be met.
r
,/
Form 1255 Rev. 5/96 A.M."SulkinGo. ChaBeslown,MA Date.~/'� / Board ofHealti ""