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HomeMy WebLinkAboutApp-Permit-ComplianceNo. — t Y RMOUTH HEALTH DEPT. COM90. YARMCJUTH, MA 02Qd4 Board of Health, , MA. FEE Sd APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location rUV,& I Owner's Name Map/Parcel# 1 3 Address „4 Lot# Telephone# Installer's Name A & B CANCO Designer's Namq Address 350 Main Street Address Telephone# W.` MA 02673 Telephone# t.s-q Type of Building ��`�� � Lot Size sq. ft. Dwelling - No. of Bedrooms -3 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 t Plan: Date �' 0 1 Number of sheets Revision Date Title Description of Soils) e r Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS (':� 1 L- All./ The undersigned agree t rth the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to p c system in operation until a Certificate of C m ' ce-has been issued by the Board of Health. ,Signed Date Q .1h,peclions No. A (0 COMMONWEALTH Of MASSAC14 SETTS FEE T'y�jS' j Board of Health, lyi N. MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( ) by: C_. 6 .,u ( (0 at fOule has been installed in a cordal e with the provisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to application No. , dated — Approved Design Flow (gPd) Installer �/Vc V _ I I Designer: LIMAJ/U l- -V/C- Inspector: 1-->LP-1 ' ► Date: / / G The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. COMMONWEALTH Of MASSACHUSETTS Board of Health, M y,( u v- k , MA. FEE S�y IA147� -c- DISPOSAL SYSTEM ['J[ CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair (grade ( ) Abandon ( ) an individual sewage disposal system as described in the application for Disposal System onstruction Permit No. , e dated��_Q/ Provided: Construction shall be completed within thr ea��ei o" �iyf tl'i d to of this permit. All local conditions m st be met. form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� Board of Health