HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH At 9 5'�Rll U S E T T S
6 i
Board of Health, MA.
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APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair() UpgradeY Abandon( ) - ❑ Complete System ❑ Individual Components
Location e
Owner's Name UJU
Map/Parcel# /* /j 69 1 A
Address
Lot# iV %6
Telephone#
Installer's Name
Designer's Name
Address `�
Address
Telephone#
Telephone#
Type of Building
Dwelling.:-. of Bedrooms
i
Pther - Type':of wilding ^:
Qther Fixtures
Pe$ign Flow (min. required) gpd
Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
3/?,
Design flow provided
Revision Date
Date of Evaluation
gpd
DESCRIPTION OF REPAIRS OR ALTERATIONS
3
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire" not to 131ace -the in peration until a Certificate of Co pli as been issued by the Board of Health.
'Signed �1 �' "� (l�'liC�l. Date
7*spections
No. 9- " "-�
Board of Health,1412 SAT (�-L MA.
,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) )Y Complete System
The ue s(i ed ereby c r ' that the Sewa e Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandonedly
( )
by: V vl
at
FEE
has been
Installer
Designer:
The issuance of this
with the provisions o 0 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
dated `' � . Approved Design Flow-�_(gPd)
Inspector:
not be construed as a guarantee that
Date: .2 �,eo
as aesignea
No. / —�� />1Z/
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby
at
FEE, V
to; Construct( ) Repair( ) Upgrade 0 Abandon( ) an individual sewage disposal system
Disposal System ConstructionPermitNo. dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this
/p/ t. All local conditions must e ret.
Date `
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Oard Of Health