HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60WDC— i-7-33e!�_
FEE
7 �' MONWEALTH OF NIASSACHUSETT
�1
Board of Health, �1 i , MA.�
APPLICATION FOR. DISPOSAL STEM CONSTRUCTION PERMIT
/YS
Application for a Permit to Construct( ) Repair( ) Upgrade ( Abandon O ❑ Complete System "e Individual Components
Location `
Owner's Name
Map/Parcel# r
Address
Lot#
Telephone# - , .,-7—
Installer's Name
Designer's Name
Address 3o :21 XZ,O�tAddress
e
Telephone#-��- l
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design flow :2� Design flow provided 3!0
�C gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
t
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 es to not to place the system in o ation until a Certificate of C mpliar,'Fe has been issued by the Board of Health.
Signed Date
9
Inspections
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1��i-�.m0C%nt 1.11M.
FEE 00
I 10 171
CERTIFICATE OF COMPLIANCE
Description of Work: _2 Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned ( )
at
has been installed in accordance with the provisions of 310 R 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. 1 Z. -6:i _, dated !' — Approved Design Flow... ., (gpd)
Installer / 40
Designer: dr/ - Inspector: ai - IS -ate: _
The issuance of this permit shall not be construed as a guaratee that the system will function as designed.
U+A5E FEE
COMMONWEALTH Of MASSACHUSETTS &4 1017
/ Board of Health, V49M ej LM4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgradet._4 Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit Nodated --,J ��.
Provided: Construction shall be completed withirubxP� {hie date of this permit. All local conditions must be met.
Form
12255Rev, 5/96 A.M. SulkinCoo.. Chadestown, MA Dat '% Board of Health
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