HomeMy WebLinkAboutApp-Permit-ComplianceNo. C (9—( tel'`
l %" , O O1�W LTH Off' MASSACHUSETTS
/4 /'� Board of Health, �L , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
PP�icati n for a Permit to Construct Repair( U rade Abandon om Tete System 0 Individual Components
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LocationS �� _r
9_ Owner's Name'�y
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Name �y
Address a3
Address
Telephone# Sr ��
Telephone#' -SZT
Type of Building � �h`� ��'er'�=u"�` Lot Sized� sq. ft.
Dwelling- No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria
10,
Other Fixtures
Design Flow (min, equir/ed) gpd Calculated design flow Design flow provided gpd
Plan. Date ' 1 l� Number of sheets Revision Date
Title
Description of Soil (s) sail I & Q/
Soil Evaluator Form No. Na e of ,Sail Evaluator �� �tnnt Date of Evaluation 140 "— L'
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees t t the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no place syste in o t' on Certificate of Compliance has been issued by the Board of Health.
Signed DateC'
v _
Inspections
No._ f FEE 0TO1
COMMONWEALTH OF MASSACHUSET
Board of Health, YA C) it k-" , MA. F j,
CTIFIC 4TE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) @<omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgrade4,.(+''frAbandoned( )`
by: SJ
has been installed in accordance with the provisions o �1-0 r�IR;15.00 (Title 5) an thea roved design'Fplans/as=