HomeMy WebLinkAboutApp-Permit-ComplianceNo.id say) ,E ta` to ; n} yN; pY4/s� FEE
r� eXI67II1 Thi` ONWEALTH ®f MASSACHUSETTS � to
Board of Health, , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(p) Abandon() - Complete System ❑ Individual Components
Location ,
Owner's Name �AIA o
Map/Parcel# Z
Address
Lot#
Telephone# _
Installer's Name
Designer's Name
Address /
Address P49, � s7
Telephone —
Telephone# -- d
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required
Plan: Date r�
Title p%. G
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
r l�� gpd Calculated design flow 3� Design flow provided -25Z gpd
Number of sheets / Revision Date /D///AP,6
Description of Soil(s) 545�r—
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Theundersi d agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further, a e t not o ce system in operation until a Certificate of C mp . nce has been issued by the Board of Health.
Signed Date �0
Inspections
No. r�- 33� C®MMONWEA TH Of MASSACHUSETTS FEE�
Board of Health, va-LAV-1071� MA. moi`
CEPITIFICATf OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ,,8tomplete System
The umlemigne ereby, certify that the Sewage Disposal System; Constructed ( ), Repaired), Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provis' n f 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 7& dated Approved Design Flow. (gpd)
Installer
Designer: ` �r'� (��,�s� Inspector: Ll Date: �'97
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.