HomeMy WebLinkAboutApp-Permit-Compliance' �N e o —f 9-oS1P3 �c v� S� I LD
� No. _ � FEE
COMMONWEALTH OF MASSAC14USETTS
pct, Board if Health, �i0S MaAMO MA. qUG 3 0 2019
APPLICATION FO -11 DISPOSAL SYSTLM CONSTRUCTION PER IT HEALTH DEPT.
Application for a Permit to Construct.( ) Repair( ) Upgrade( ) Abandon( )-,9-Coinplete System D IndividualComponents
Location l
Owner's Name
Map/Parcellk - Z„
Address 2itit- S
Lodi
Telephone#
Installer's Name UAL -
Designer's Name s
Addressddress
glz
Telephonelk
Telephone#
Type of Building ;Q
Dwelling -No. of Bedrooms.
Other -Type of Building _
Other Fixtures
Design Flow (min, required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Lot Size 15 )-' 2- sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
_ gpd Calculated design flow Design flow provided
Number of sheets Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to place ate system in operation until a Certificate of Cof Co �1�been issued by the Board of Health.
Signed Date _
COMMONWEALTH OF MASSACHUSETTS f ,J, t , � FEE,
Board a%7-Iealth,-1d?.B1mm0T7 , MA. A )
e
CERTIFICATE OF COMP "�o\
Description of Work: ❑ Individual Component(s) P -Complete System
Al,k,
The undersigned her certify that the Sewage Disposal System; Constructed ARepaired.( ), Upgraded ( ), Abandoned ( )
ate f, ii r
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plansrelating to
application No. ) i - a•' dated Cl- { P" ("'-'p' Approved Design Flow '" (gpd)
Installer l 9 1 (1) i• o tri �� c+✓�, .�' `1 .
a
Designer:f<''�,� Inspector: 'Ore `r4s`yti-w'+r"~r z Date:+
r
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. C -4 )f=-� e� �,��.;a..°� ge:��o-•aL G....,y.C_;AP' • FEE `�9.i11 C?tJ
,w ( T)41
COMMOMAI.TII Of MASSACHUSETTS
Board of Health,MA.
DISPOSAL SYSTFM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(,t) /Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 1 {'' n) /t. " ' LT , 7 Ll c" Eti , i 1 { ) as described in the application for
Disposal System Construction Permit No. Ff "'") ) , dated ``°' _ $ �°. ti s`
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
dd r, s°1 r 'gYg
Form 1255 Rev. 5196 A.M. Sulkin Co. UndeOn MA Date " 1 8" Board of Health a"''� '�`"`sS
IM,