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