HomeMy WebLinkAboutApp-Permit-Compliance�No. ro C[9--Wof(O FEE
a COMMONWEALTH OF MASSACHUSETTS
Board t f Health, V W W J VAh , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( 0 Complete System ❑ Individual Components
Location t
! FIj
Owncr's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address
Address ''x
Telephone#
Telephone "',
Type of Building
Dwelling -No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: D:IteC,:�P 9A
Title Z:Quj I UI V t
Description of Soil (s) _
Soil Evaluator Form No.
_ gpd Calculated design flow
Number of sheets _
Name of Soil
Lot Size � " sq, ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with dieprovisions of TITLE 5 and
further agrees to not 1 e the tet operation until a Certificate of Co pGanc phas been issued by the Board of Health.
Signed Date 0�i
�4;_
No.
COMMONWEALTH
�'�/1I �p'p7 ,(��^ MASSACHUSETTS
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'l.®1°dl' ON I"Y EAL H V.1'll.' 1'dYYS9ttY'CHi SETT:9 t�� 1\gFCL .`Stw> r, f�
Board of Health, ygleko (I krrm- NIA. $,) �2)C,y- _f..
CERTIFICATE SOF COMPLIANTC 6 Z e ce e, (t ,
Description of Work: ❑ Individual Component(s) 0"Complete System
The undersi nedd�herebyicetufy that the Sewage Disposal,Systenr; Constntcted
by: O, Repaired O, Upgraded .(,);'`Abandoned ( )
'i 94.rtp ii:) i li 3`
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Tide 5) and (lie approved design plans/as-built plans relating to
c Z ;
application No. l �c;, °" (`'( ,dated 1"" • �`'-�t � .,...Approved Design Flow (gpd) " ^' p' ��; �" E:.� `w. -^o ,mow(
Installer o °_-•'v 9 c i a Je p:... ,,. `� E:,ef. .., -„=._-y va..,- t rv:1f-•6.._° t�... i"ll_.gt �.
r. f t c ^f r✓ rs hl`sntai: "P t ^� ��<@' �a ;'a._.�r Date:
llesignet".dr
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Oc— k1
COMMONWEALTH OF MASSACHUSETTS
FEC
C. (!n 1(4 <<o
Board of Heath, A (c'm 0 um MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade(,) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No. (ei dated � 'l
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
C�'_ t .. uet " 13j M
Form 1255 Rev. 5l96 A.M. Sultrin Co. Ctaleslw+n, MA Date C 4t` / lBoard of Health .. (./t,.,,,°-. °