HomeMy WebLinkAboutApp-Permit-ComplianceNo. &a- —1 i'v—Gro IEE 6 , 0
/ 1-6�1 COMMONWEALTH OF MASSACHUSETTS II(o2__0
Board of Health, Y&gft Im MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradandon( ) - alComplete System O Individual Components
Location _)_�A I'X
Owner's Name e--
Map/Parcel# 14H
L`-
Address I�
Lot#
Telephone##
Installer's Name ob,
Designer's Name )'
Address 13b U614S
��KX
Address 4 0W44, �:W e ,�Iujw ld,
Telephone# (50103916.%luTelephone#
_5-0 b- (p,5,
Type of Building Lot Size sq. £t.
Dwelling - No. of Bedrooms o Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided 0 1 gpd
Plan: Date 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
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es to not to lace thesyste ixx eration until a Certificate o /Co plliiaiace has been issued by the Board of Health..
Signed mo, Date L✓
Inspections
FEE. C+
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �—� , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) �.omplete System
The 1
1
11
dersigned hereby,V`ertify, that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded.( 'Abandoned
athas been installed in accordance with the revisions of 3JQ CMR 15.00 (Title 5) and the a oved design plans/as-built plans relating to
application No. t� •� dated Approved Design Flo _7 (gpd)
Installer
Designer: m :_�j , t q, 1 . 'n Inspector: U Date:
The issuance of this permit no a construed as a gua tee that the system will function as designed.
No.h, c a
c FEEJ
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL S1TSTEM CONSTRUCTION- PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(. bat don ( ) an indiv=idual sewage disposal system
at <; r� ,� P i i It 1 ! as described in the application for
Disposal System Construction Permit No. dated -. — L/
Provided: Construction shall be completed within d}r. �ss f thr date of this permit. All local con e• ions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health