HomeMy WebLinkAboutApp-Permit-ComplianceOW)C -3fcE � pig �C�IL� FEE_(2Do
No.
20 -ostp COMMONWEALTH OF MASSACHUSETTS 2-043
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairx Upgrade( ) Abandon( ) - ❑ Complete System Abadividual Components
Location
W 5° %
!�.T '
Owner's Name L l,4
Map/Parcel#
% "�
Address '-11 P --r -A 'ZZ{ pA -r
Lot#
Telephone#
Installer's Name
_
y�^�
Designer's Name MIZA
Address
t`r
��
U[. -Q Address
Telephone#
ephone#
Type of Building
Dwelling - No, of Bedrooms
Other -Type of Building _
Other Fixtures
I
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description ofSoil (s) _
Soil Evaluator Form No
Name of Soil Evaluator
No. of persons
DESCRIPTION OF REPAIRS OR ALTERATIONS :rLs-r E_L. M Cgs "-?,
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
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 not to place the system in opqrAtion until a Certificate of Compliance has been issued by the Board of Health.
Signed_ Date Z-20--Zp
Inspections
No. FEE
n`a..1 ° wc.,^w?'B ,G ;...,.' .,.)
FCE x ,5
COMMON LTH OF N ASSACHUSETTSf
Board of Health, ViI12414 iti-(`H MA.
C
CERTIFICATE OF COMPLIANCE
Description of Work: f4Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (N�, Upgraded ( ), Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application �N�o ` (� tib' dated Z I J -11 .' Approved Design Flow (gpd)
Installer';a
_ i)a°at'?c 0,
Designer: KVA Inspector ms`s +"(^ re u7e&c,,t. Date:
0' "
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH
OF MASSACHUSETTS
v ✓.' i' . S L. Board of Health, .9 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(at PIT-
)
FEE
c
Upgrade( ) Abandon( ) an individual sewage disposal system
Disposal System Construction Permit No. +'( `�' is-' , dated'.
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.
Form 1255 Rev. 6/96 A.M. cuikin co. ChakS wn,MA Date ":'t` Board of Health