HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTH 4LTH OF MASSACHUSETTS
FEE 6
02118
Board of Health, y 2t1 1'1 , MA.
PPLICATION FOR POSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(Repair UPgrade(t"bandon(U Complete SystemX11dividual Co
m onents:
Locationq Wo
Q
.1 Owner's Name
Map/Parcel# d ��p S
Address 54ttW
Lo,4Telephone#
Installer's Nam ,\
Designer's Name
Address IR
Address
Telephone#
Telephone#
Type of Building' Cl ti Lot Size
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 gpd
Plain: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
Inspections
above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and;
em in opSp on until a Certified of Compliancoas beep issued by the _ _ `_Fl,r
Date
if
JUN U 6 2019
HEALTH DEPT.
No. IC�i FEE ✓.
COMMONWEALTH LTH OF MASSACHUSETTS � �� (V)
Board of Health,y,ARM OUTS , MA., J101 a e-0
4
CERTIFICATE Of COMPUANI CE '
Description. of Work: Individual Components) ❑ Complete System'
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ); Repaired), Upgraded( ) , Abandoned (
/
v' P
has been installed in -f� e with the provisions 310 CMR 15.00 (Title 5) hand the ;approved design plans/as-built plans relating to.
application Nod "'iQ Aated I rid . `Approved Design Flow (gpd)
Installer •'�j u�
Designer: ---- rg Inspector: Dater
The issuance of this permit shall not be construed as a antee that the system will function as designed.
No. p1G 14"� CI'" -3 Gt' J r C.0 t� ? , FEE y
fig- M L- COMMONWEALT14 Of, MASSACHUSETTS 7�t 5
Board of Healtla, i/g7e./4lol. nT MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repan Upgrade( ) Abandon( ) an individual. sewage disposal system
-,f q f °nt. 1, 1G1 1 _ 0a. -Ti -L as described in the application for
`GG=
Disposal System Construction Permit Na - of dated % .
Provided: Construction shall be coinpleted h u three years of the date of this pe • it. All local condi 'ons must be met.
Form 1255 Rev. 5/96. A.M.Sulkin Co. Chadestown, MA Date . --7--,15 1 Board of Health /