HomeMy WebLinkAboutApp-Permit-Compliance7a.
No5-7
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C®MMONWEALT14 OF MASSACHUSETTS � Cil ��7
„• Board of Health, YARIlIlIC)l ITH HEX -TN n MT
APPLICATION FOP, DISPOAT,=,W�JJAUCTION PERMIT
Application for a Permit to Construct( ) Repair() Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
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Owner's Name
Map/Parcel#
Address 3
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Lot# r3
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Telephone#
Installer's Name
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Designer's Name
14E
Address j
STJls
Address_Ai
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Telephone#
Telephone#
Type of Building ��c dGc e✓�'I L-�- 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 flo ` Design flow provided gpd
Plan: Date //--
'� Number of sheets Revision Date
Title
Description of Soil(s) SWWOH k"V
Soil Evaluator Form No. Name of Soil Evaluator "✓- Date of Evaluation ( Cil 17
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to inst3R the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur %a"idhstemJn-o9erfttu*m' until a Certificate of C pliance has been issued by the Board of Health.
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Signed Date
Inspections
No.
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'1,®MO V'�Y EALT14 Of MASSACHUSETTS Fb1V FEE
,(�1`�ll
Board of Health," MA.
CEPITIFICAA OF COMPLIANCE
Description of Work: ❑ Individual Component(s) SQ -Complete System
The undersigned/)hereby cer ' that t Sewage Disposal S vmt Constructed ( ), Repaired ( ), Upgraded (4-,<Tbandoned O
by: b 4
at�
has been installed in accordance with the provisions oo7310 CMR 15.00 (Title 5) and the p oved design plans/as-built plans relating to
application No. dated%� 7 �/ C1J Approved Design Flow (gpd)
Installer 9
Designer: Inspector: 16; az'114&Date:
The issuance of this permit shall not be construed as a guarantee th the system will function as designed.
No._%/� ��` . y�C._y�% \ . FEE
COMMONWEALTH Of MASSAC14USETTS g2 7)-,7
Board of Health, V Gid W10 , MA.
DISPOSAL SYSTEA CONSTRUCTIO NPERMIT
Permission is hereby granted to; Construct( ) Re air( ) Upgrade (4 -Abandon ( ) an individual sewage disposal system
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