HomeMy WebLinkAboutApp-Permit-ComplicanceNo. FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, d ` 101 I E HAPPLICATION FOP, DISPOSACCSYM-9 W"WWTION PE MIT
Application for a Permit to Construct( ) Repair( ) Upgrade(61"Abandon() - Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Address ®� S l
esigner's Name
Address .0v ri
Telephone# ._ '� .. �_!�
Telephone# _ -
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) y gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title A '
Description of Soil(s) A 2d
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 a to not to place the system in operati until a Certificate of Compliance has been issued by the Board of Health.
Signed fA Date
Inspections
No. FEE
COMMONWEALT14 Of MASSAC14USETTS -k
Board of Health,�113 i'fi MA.
CERTIFIC OF COMPLIANCE
Description of Work: ❑ Individual Component(s) *omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (ter Abandoned ( )
'�
.
at
has been installed in a cordance wits the provisions of 10 CMR 15 00 Kitle 5) and the roved design plans/as-built plans relating to
application No Q � F dated % -O . Approved Design Flow-�K(gpd)
Installer e
_
Designer: .' Inspector: ( Date:
The issuance of this permit shall not b& construed as. a guarantee that the system will function as designed.
No. t/CJ 'C� (�� rte` C�4 ✓/¢" ""'�(r� t.,U�/Cs FEE C'
COMMONWEALTH Of MASSAC14US ETTS
Board. of Health; MA
DISPOSAL. SYSTEMCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( y -Y Abandon ( ) an 'individual sewage disposal system
at % �� �� t1 �' �., .. 6&2as described in the application for
Disposal System Construction Permit No. daked 4 - AjY')
Provided: Construction shall be completed within thxea4�oif the date of this p rmit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date "q' . A` 6 G Board of Health