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HomeMy WebLinkAboutDisposal System Application/Docuements0 p 2 z 0. ■ y 'k (A � pd c G' W a- 1 R C 0 0 1 v � 7 y � O 90 T ate. Q1\v, G � c � 1 � Iz N y K J 7 O et C�1 o � ur) n � H m WY m C" o m T O No. -32LL,�� — a V - i9�; COMMONWEALT14 OF MASSAC14USETTS Board of Health, Wil FEE APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System © Individual Components Location Owner's Name Map/Parcel# _ _ Address t_M L2 e Wtt c C1 Lot# Tele hone# '1 p 5 'Y ' ,�C • � ��I 1 Installer's Name �} b (tj Y.XCc� fit. , Designer's Name 1 j Address 9-, opt ` �30 be ,-,d W ( Address Telephone# 02, ���'� ' Ub 5 3 Telephone# Type of Building Rk' Cl'i Dwelling - No. of Bedrooms _Other - Tvpe of Building Other Fixtures Design Flow (min. required) gpd Calculated design flow Plan: Date Number of sheets Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator Lot Size sq. ft. _- Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided gpd Re-6sion Date Date of Evaluation DESCRIPTi )N OF REPAIRS OR ALTERATIONS. [ 1Q Ok h c 0 rA f ` [ r n Qrl � The undersigned jg es to, install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tgnot to placelthe system in operation until a Certificate of Compliance has been issued by the Board of Health. aI Signed CLCf-, Datel--� Inspections f _ % 5 5 No. COMMONWEALTH OF MASSACHUSETTS } FEE f n, Board of Health, _._ '; n rriln� 'r. MA -!"!; t � CERTIFICAT[ OF COMPLIANCE Description of Work: 0 Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (,ti), Upgraded ( ), Abandoned ( ) by: 61 3 6 41( (0. rr at 46 1_i Q ��1f c Cl 1C ur1 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. r)`/ :I v `— dated i -1 Approved Design Flow y (gpd) Installer Designer: Desi _ h c c-- g � ,- Inspector: .( � � Date: The issuance of this permit shall not be construed as a g&imaeteet5at the system will function as designed. No. COMMONWE LTfl OF MASSACHUSETTS Board of Health, k r MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an indivdual sewage disposal system at as described in the application for Disposal System Construction Permit No.'// v ` dated Provided: Construction shall be completed within three year of the date of this permit. All local conditions mast be met. Form1255 Rev 5M kM SulkinCo ChatedagMA Date —% / Board of Health f/ a m m ®o c c� tp �} a C Q O m m � $ M t m CL v c m A c m m m ti a I�1 3 C m N a N 0 � � � � P Sm x G- � M �► o 0 m, D 3 � a o m � � '� 3 V m N CA W