HomeMy WebLinkAboutApp-Permit-ComplianceNo. : - 2 . �. FEE
COMMONWEALT14 OF MASSACHUSETTS �,JJJY
Board of Health, , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(4Abandon() - OYComplete System ❑ Individual Components
Location
Z ��C
Owner's Name
Map/Parcel#
7
Address
'
Lot#
1;�,
Telephone#
Installer's Namev�
Designer's Name A7
Address
Address
Telephone#
c J 1
Telephone
�,
Type of Building Lot Size t 7 sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder (/-6
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re u e) /(/ gpd Calculated design flow � Design flow provided gpd
Plan: Date '7-u a` 2 Number of heets l ®Revision Date
Title %� ✓� `l �® 7 :�
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described -Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to lac a sys m in operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed Date 1�
_i�.
Inspections
FEE
COMMONWEALT14®F MASSAC14USETTS � 2,
Board of Health, ` ' �/ MA.
CERTIF2mplete
TE Of COMPLIANCE
Description of Work: CJ Individual Component(s) System
The undersi ned hereby c-erqfy that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded (Abandoned (
by:
at /
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. 02 _1-32—, dated � � a Z...Approved Design Flow (gpd)
Installerzz
Designer: Gam/ Inspector: Date: t
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. C. 45 � FEE / c✓. C/C ?
COMMONWEALTH OF MASSACHUSETTS
Board of Health,G_'%' ,0V , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( Repair( ) pgrade((Abandon( ) an individual sewage disposal system
at /f �" / /�' as described in the application for
Disposal System Construction Permit No. d �� Z, dated �4,? r o:
Provided: Construction shall be completed within ter rooft� he date of this p it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date V r 40Board "of Health vC Glc