HomeMy WebLinkAboutApp-Permit-Compliance�dNOG7A-�S�ID'C �'��zC'le .�J
No.
FEE
b�—� R -2u cx� RFs 3i� COMMONWEALTH OF MASSACHUSETTS Rfc iv
Board ?fHealth, o , MA. MAR 03 2020
APPLICATION P®R DISPOSAL SYSTEM, CONSTRUCTION PERMIT HEALTH DEPT.
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System 0Individual Components
Location O
Owner's Name
Map/Parcel# i2:d 1 615
Address PUn(fiA
01
Lot#
Telephone# NQ —' lJ:
Installer's Name W ')
Designer's NameDc)�)
Address
Address
Telephone# i
Telephone# (�
Type of Building —8 Q's C (k 1/7 - i c Lot Size / 5 sq. ft.
Dwelling - No. of Bedrooms C-5 Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures /"�
Design Flow (min� . required) 5'5�gpd Calculated design flow 6t0) Design flow provided .6 ) gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No
OF
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 agreesP�ttot to place the system in operation until a Certificate of//f� Compliance has been issued by the Board of Health.
Signed !/----�Date
Inspections
No. 6(.1(;%
Description of Work:
The undersigned het
by: �( i
at 11 t�1k(i
has been installed in
application No 2t
Installer
C®MNI®NLTII OF �✓IASSACUS�TTS -' FEE ` "� ,
C� ! n
Board of Health, Vle) IJ 9h W.
6
CERTIFICATE OF COMPLIANCE
1] Individual Component(s) 0 Complete System
by certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded'(, Abandoned ( )
.ccordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated , i Vy t.'lu' Approved Design Flow '"! (gpd)
Designer: L4 ,1 kP f Eq C H I/ F..t1_ 4'
The issuance of this permit shall not be
Inspector:
Date: e
t a
as a guarantee that the system will function as designed.