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HomeMy WebLinkAboutDisposal System Application/Documents/[/� yJ a, No. �yj � { �/ P � r J �C / i ' Gl y FEE COMMONWLALTLI OF MASSACHUSETTS 01 6 Board r f Health, _ 11,,E Z` APPLICATION FOR DISPOSAL SYSTEM CONSTRICTION PERMIT Application for a Permit to Construct( ) Repaii-W Upgrade( ) Abandon;: ) - ❑ Complete System ❑ Individual Components Location ` �f ` 1 Owner's Name Map/Parce—1 G L1 Address L Lot# L't' Tele hone# tk— Installer,ps Name Designer's Name _ v _ t - '': V Address �„ ,t M1 4�� Address C t J \ Telephone# - cL ��lL 1 f �S2- {� Telephone## Type of Building . f t ,y� Lot Size li - — sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Tvpe of Building _ Persons o No. f — p Showers ( ), Cafeteria ( ) Other Fixtures c� Design Flow (min. required) gpd Calculated design flow r� Design flow provided L 6 —1 gpd Plan: Date i L' L Number of sheets ._—I Revision Date Title Description oFSoil(s Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS k `i 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 operation until a Certificate of Com liance has been issued by the Board of Health. Signed Date Inspections 1W COMMONWLALTLI OF M �•.d`��F> E---- ASSACLIUSETTS �. � r Zone -}�' " CU/tP„ j a j l jf Board of Health, 1 �Q NOT a lla r� MA. '� VIL CERTIFICATE OF COMPLIANCE C � E>75 lefk Description of Work: (Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: CN 1- v at • iwl 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 No. c/ OR, dated / l� .J�i Approved Design Flow d (gp) 36d dt*5e t. on,./ n7 /344, )V,yt Installer`• . C W . C6Y\ Inspector: T1 G� _ Date: The issuance of this permit all not be construed as a guarantee that the system will function as designed. No. FEE �_ COMMONWEALTH OF MASSACRUSETTS Board of Health, \ t(_ .1 1 y _ MA DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(,) Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. 2t - 1 , dated _l J d' Provided: Construction shall be completed within three years of the date of this p t. All local conditions must be met. Form 1255 Rev.5/96 A.M. Sulkin Co. ChaftmmMA Date J/ t — Board of Health �� 0 0 a H 5 CL 0 m Co vo r n7 o � O w O r I f i O � a � y z7 0 � � K m <a 0 r] 7 �cr r � o �o x� n �, � r�r H O �> �. ro A' Ov � i y I f i I R m 1 KI-f C,(,(C� I Pf-d 't� 8AT�/ hl+n%C, Z R� o N1 Ov(Iq� goo rq RECEVVED ,BAN 112024 HEALTH DEPT, wy, in . 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