HomeMy WebLinkAboutApp-Permit-ComplianceNo. �
FEE
/-0 IAW(P-r- COMMONWEALTH Of MASSACHUSETTS /0j Z071"Xf
J,/z,5,UTH HEALTH Board of Health, 146 R 9-3
.APPLICATION FOP, DISP(WATATfflPMP`61ffMUCTION PERMIT
Application for a Permit to Construct( ) Repair (,1�Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 3 fid
Owner's Name
Map/Parcel#
Address GJ�
Lot#
Telephone#
Installer's Name �'
Designer's Name
Address 0 AX h
Address o�fi
Telephone#�`
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms L�Yl7 _ 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
Plan: Date Number of sheets -'3 Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to not to placethe system in operation un ' a Certificate of Compliance has been issued by the Board of Health.
�- Signed i«�/�//� ��1.� Date r%
Inspectiogis oF j-
f0 FEE
COMMONWEALTH OF
�. �.
Board of Health, , MA.
CERTIFICAR OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersizued hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (P< Upgraded ( ), Abandoned ( )
by: '
at
has been installed ina cor with th ro 'ions 10 CMR 15.00 (Title 5) an oved design plans/as-built plans relating to
application No. ", dated r . Approved Design Flow (gpd)
Installer 3w— / _ / ,
Designer: !� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. 07
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �7 MA.
DISPOSAL SYS CONSTRUCTION -PERMIT
Permission is hereby granted to; Con ruct( ) Repair( U
at 3 ; —
Disposal System Construction Permit No.
FEE v
c( ) Abandon ( ) an individual sewage disposal system
v6/Afe221 i as described in the application for
Provided: Construction shall be completed withiinn_g/� of the date of this r. t�Al�l/ocal co;Qd' ��' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date `r (/--/-Board of Health �:�f