HomeMy WebLinkAboutApp-Permit-Compliance! No. i E w hl FEE
COMMONWEALTH OF MASSACHUSETTS ff-
Board of Health, , MA. 1
APPLICATION FOP, DYpgr.d,SAL SYSTE 9[ CONSTRUCTION PERIL IT
y Application for a Permit to Construct( ) Repair () Abandon( - ❑ Complete System Ulndividual Components
Location
G Owner's Name SW
Map/Parcel#
,��° �
Address xg�"(Tlt-Non!m )11 h
Lot# ./ `,.
Telephone#
Installer's Name
Designer's Name-V,0A./ "
Address
l
Address �V
Telephone#
Telephone# - b
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder A 14
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) �+ :7 7?n gpd Calculated design flow Design flow provided */J-1 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
,4 xcuw n ' V A,Q-f-
o The undersigned agrees to 'install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a-lbes to not to a the sys in operation until a Certificate of C-oomp ' ce has been issued by the Board of Health.
Signed �/ � Date / «J 7
a.
Inspections
No.7 FEE J �✓
COMMONWEALTH OF MASSACHUSETTS
Board of Health, L�/d M L Vi"n� , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: )42idividual Component(s) ❑ Complete System
The unders' ed hereby certify /that �the Sewage Disposal System; Constructed ( ), Repaired ( /,Upgraded( ), Abandoned ( )
by:
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and�lye�pproved design plans/as-built plans relating to
application No. 9 % �7 , dated . Approved Desizn Flow _ ��,�LL (Lypd)
Installer
Designei
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.