HomeMy WebLinkAboutDisposal System Application/DocumentsNo: 1 1 ` - 2 c) ' FEE tiJ�J
COMMONWEALTH OF MASSACHUSrTTS �44 04a
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Board of Health, _ y2 =M— Qy'r1f '
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT E
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System aIandi;vidual Components
Location G� t>'�� t ((,.. Owner's Name 1r(
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name CtPC (CrI SQ Z t CVedw
Designer's Name
Address }�,Q• 1j0y 46 16,x
Address
Telephone# " r%L/O V
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
j W c i1- A
Lot Size
No. of persons
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design flow provided , gpd
Revision Date
Date of Evaluation
The undersigned agrees to install the abovd desrn"bed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to place Cbe systepr m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date [7J I
Inspections
i
No. "..Q# Q - 20 —
COMMONWEALTH OF M�4SSACHUSETTS FEE �—
.� ,Nuis, Q,�-#Ld D45
I f(Board of Health, _ O MA.
CERTIFICATE Of COMPLIANCE
Description of Work: UIndividual Component(s) ❑ Complete System
The undersigned hereb ceru that the Sewa a Dis osal S tem; Constructed l g P Ys (), Repaired (;�, Upgraded ( ),Abandoned ( )
by: _ ; Q CO _ c ur c c < <y
at
has been installed in accordance with the prrisioz s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 1 dated Approved Design Flow , 1 4+ (gpd)
Installer
Designer: Inspector: Date:
e issuance of this permi
t shall not be construed as a guarantee that the system will function as designed.
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20-�220
FEE
COMMONWEALTH OF MASSACHUSETTS GL
3
Board of Health, _Y,&f�m04* MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an Indivdual sewage disposal system
at
Disposal System Construction Permit No. 7-0- I3- dated tO I � 7DZD
as described in the application for
Provided: Construction shall be completed within three years of the date of this perm' .,,All l condt`pons must be met.
Form 1255 Rev. 5M A.M. Sulkin Co. CharleslM MA Date J
Board of Health- �