HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, '�/V , MA.
'APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( �pgrade( ) Abandon() - ❑ Complete System d-hidividual Components
Location
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Owner's Name C✓V r'A- 10
Owner's
Map/Parcel#8
jLl
J 1'/
Address
Lot#
Telephone#
Installer's Name � O
Designer's Name
Address
3,5-,9 AV/iv
Address
tTelephone#
j Gl F
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
e.
Description of Soils)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS £ �r.f A,G £�.r%� k
na s�(- cfl $ , mak. u - �_ NG I • &u )
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to not to place the system K'i operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date %' l 00—
Inspections 0—
Inspections
FEE
COMMONWEALTH OF MASSACHUSETTS _
Board of Health, , MA.
;r --CERTIFICATE OF COMPLIANCE
Description of Work: C§'°Individual�Component(s) ❑ Complete System
The undened hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,`Upgraded ( ), Abandoned
rsi ( )
by: �r � & P 141� C o 3-f- tw- �W lr.
at C t tt e Gi / % / ,� /L GM 41f
has been installed in accordance with theprovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application fad- 1Z 7 dated c -I<— . Approved Design Flow""""'"' (gpd)
Installer Y
Designer: Inspector: Date:
G
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. CJ FEE
-. COMMONWEALTH Of MASSACHUSETTS'
�a
Board of Health, MA z " '4
DISPOSAL SYSTEM CONSTRUCTION PERMIT 0 V7
Permission is hereby granted to; Construct( ) Repair( } Upgrade( ) Abandon( ) an individual sewage disposal system
at 9 0, C / 7- /P-), N ' Yom"' as described in the application for
v
Disposal System Construction Permit Nk. dated �l J
Provided: Construction shall be completed ne,
n (�' Ye
� -ars of the date of this permit. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Boston, MA Date U 1 Board of Health ,
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