HomeMy WebLinkAboutApp-Permit-ComplianceNo. V' T ' i
-3
YEALTH Of MASSACHUSETTS
FEE'0o
C40653
Board of Health, MA,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( )'Repair( ) Upgrad Abandon( ) ❑ Complete System—U Individual Components
Location
Owner's Name
Map/Parcel# / %
Address /!C�
Lot#
Telephone#
Installer's Name
Designer's Name
Address _76
Address
Telephone# — ��I
Telephone#
i
Type.of Building _ - Lot Size sq. ft.
Dwelling - No. ,of Bedrooms - Garbage grinder(
Other -Type of Building No, of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided -1 gpd
Plan: Date Number of sheets Revision Date.
Title
Description of Soils) o a _ggz
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 agpws to not to place the system m opera ' until a Certificate OfL Compliance has been issued by the Board of Health.
Signed Date
Q
Inspections '9''/d Z 4 1d101A of L
a
No. � 7 O
&101"I EKE.
MMONWEALTH Of MASSACHUSETTS
,.• Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work:dindividuat Components) ❑Complete System
The tindTs�gned hereby, certify that the Sewage Disposal System; C onstructed ( )', Repaired ( ),Upgraded Abandoned O.
at
has been installed}`acro d ce with the pro��si . ras of 0 .CMR 15.00 (Title 5) ar t proved design plans/as built plans relating to
application No. dated . Ai)T)rovedL Design Flow (gpd)
Installers 1, s` lr.?� ,�-+
Designer: PQN�� ik�(SyCS ' Inspector: :f. Date.: r7
The issuance of this permit shall not be construed as a guaraetfee that the system will function as designed.
FEE" U • 00
COMMONWEALTH Of MASSACHUSETTS 11(053
Board Yof Health, l � , AM.
DISPOSAL SYSTEM CONSTRUCTION ERMIT
Permission is hereby granted to Construct( ) Repair( )Upgrade r"Abandon ( ) an individual sewage disposal system
at rl"i --> . as described in the application for
Disposal System Construction Permit No % , date �A '
Provided: Construction shall be completed within/airs of the. date of this per '"l local con ,id s must be met.
Form 125 Rev. X/5/96: A.M. S [kin Co. Chadestown,MA Date,t .ard of Health `