HomeMy WebLinkAboutDisposal System Application/documentsFEE _J
Name of Soil Evaluator
COMMONWFALRI OF MASSACHUSETTS
Board (if Health,
APPLICATION FOP, DI POSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Rcpair ) Upgrade( ) Abandon( ) - O Complete System ndividual Components
' LocatiotLjxi&1j)--11Owner's
Name
Map/Parcel# Address I
Lot#
Telephone# /, ..
Installer's Name ►
Designer's Name
Address '
Address
Telephone# UiV�
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (mi-i. required) �O—X t S i , !4 gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s) w
Soil Evaluator Form No.
DESCRIPTION 'OF REPAIRS OR
I.ot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ) , Cafeteria ( )
Design flow provided u�',- 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 sys m in operation until a Certificate of Cgmpl' ce has been issued by the Board of Health.
'I
Signed_ Date �O 7
Inspections
1/
No{'}js•,1-*A FEE
COMMONWFALTLI OF MASSACHUSETTS
Board of Health, Yain� /,st A'1^1'1 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: "n vidual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired,,"<Upgraded O, Abandoned ( )
by:
at \ — has been installed in accordance with the pro, o s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �7`�- 1 `d dated i` 1 Approved Design Flow i\1 _(gpd)
Installer 19= h n ► V AL)Q r�
Designer: 1V�a� J) t%Inspector:
The issuance of this permit shall not be construed as a guarantee
No.
Date:
i
the system will function as designed.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, �Sdi-�� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) RepairV Upgrade( ) Abandon( ) an indhidual sewage disposal system
at ) , as described in the application for
Disposal System Construction PermitJNo. ' IV ' __, dated
Provided: Construction shall be completed within tkree-yeass of the date opermit. ocal conditions must be met.
Form 1255 Rev 5/96 AN Sulkin Co. Chak-Won, MA Date I") Board of Health
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