HomeMy WebLinkAboutApp-Permit-ComplianceNo. 01--3—�4 FEE " V/d 0/
COMMONWEALTH OF MASSAC14USETTS
Board of Health, YI-74 , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (t<Upgrade ( ) Abandon( ) - ❑ Complete System lidividual Components
Location 3'4 5`ll(//P7- 4., W _
Owner's Name Xd WAIj 04,r 0? 6A-,,4L�
Map/Parcel#
Address se � dyj' %` y 1/v _
Lot#
Telephone#
Installer's Name 4 le C ,41vc p
Designer's Name
Address Sp -Y�/P
Address
Telephone# �'p p' !� f -� ro O
Telephone#,
Type of Building // e 1/3 4 Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided gpd-
Revision
pdRevision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS /,V.4 I V' i- / "L, 'r 1/du 5 i' -;;<,, 4rW /,4, ioa `'' <-
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr to not to place the system in op ration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date /� o
Inspections
No. 7 FEE
COMMONWEALTH OF MASSAC14US ETTS
Board of Health, 4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: "Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4. Upgraded ( ), Abandoned ( )
at .S" 6 �`. "GAP ?' 1,-.,,4'r°
has been installed inaccordant with the provi 'ons of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated - d,5 . Approved Design Flow. (gpd)
Installer
Designer: Cl-"' Inspector:
Date: I
The issuance of this permit shall not be construed as a 9uar4e tha/the system will function as designed.
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No -0 FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, , MA,
DISPOSAL SYSTEM CONSTRUCTION, PERMIT
Permission is hereby granted to; Construct( ) Repair( "''Upgrade ( ) Abandon( ) an individual sewage disposal system
at /`/t"�'B Y as described in the application for
Disposal System Construction Permit No. 7 , dated
Provided: Construction shall be completed within three years of the date of this p it. 1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ?V:5Board of Health
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