HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
10'a,7-1 C/Ns; e2 77COMMONWEALTII OF MASSACHUSETTS
a/LS Board of Healt1l''U11'TH HEALTH DEP
APPLICATION FOP, DISF"S�&SM"PCOWTRUCTION PERMI��
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon() - ❑ Complete System ❑ IndividCai`Components
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Location
Owner's Name
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Map/Parcel#
Address��
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Lot#
Telephone# Wed
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Installer's Name Ce
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Designer's Name
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Address
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Address (,(3
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Telephone#
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Telephone
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Type of Building S-Qe_ ;? 1lK(y Lot Size sq. ft.
Dwelling - No. of Bedrooms Z Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures _
Design Flow (min. required) gpd Calculated design flow Design flow provided _;;>A/ S gpd
Plan: 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 400 5A t `O --\ U +tjl-,'5
e4kk e L!. /600 tp n le 4---, 4 —
gkt &,& gad wL a-�A ouW (C; avh&
The undersigned agrees to install the above described -Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreA to not to plac a em in operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed Date
Inspections
No.
Description of Work:
The undersigned hei
by:
at
has been installed in
application No. Q
E,
COMMONWEALTH Of MASSACHUSETTS FEE
Board of Health, �le MA.
CERTIFIC&OF COMPLIANCE
!SI Individual Component(s) Complete System .
)y_ certify that the Se e Disposal SystemConstructed ( ), Repaired Upgraded ( ), Abandoned O
�� • �
with the provisions of 310 CMR 15.00 (Title 5) and th/� a pr �,Pd design plans/as-built plans relating to
dated ' /�� Approved Design Flow�� � gpd)
Installer C Mm—_
Designer: �Cr`%Y en d�Cle. Inspector: Date:
The issuance of this permit shall not be construed as a guarwftee that a system will function as designed.
No. FEE
Board of Health, ) I"'f' w MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebgra to; Construct( ) Repair( )•.,,Upgrade( ) Abandon( ) an individual sewage disposal system
at V as described in the application for
Disposal System Construction Permit No. J// r7/ dated
w YvGCJ .
Provided: Construction shall be completed within s of the date of this pert. All local
conditions wiwt be met.
lT / "
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date I % ' / / Board of Health rr /
A447J