HomeMy WebLinkAboutApp-Permit-ComplianceNo. �1
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UAl"Al F. i, Vkl " , l_UIVIMUN W LAUH U� MASSA �#1 ATIS
Board of Health, YA Zjj L01%7-W , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
pplication for a Permit to Construct( )_Rep ," ) Up ate() A ndon() - 0 Complete System ❑Individual Components
s ,
Location ''
Owner's Name
Map/Parcel#,s►LZ,1�Address
Lot#
Telephone#
Installer's Name t�PAJ V,
Designer's Name -yr�
Address
ess
Telephone# '►� r„
Telephone#
Type of Building Lot Size KP Z g 0 sq. ft.
Dwelling - No. of Bedrooms -,, Garbage grinder �7 11
Other - Type of Building YF`.+7 a /�A ev T No. of persons _Showers( ), Cafeteria ( )
Other Fixtures %"D
Design Flow (min. required) /fit �U gpd. Calculated design flow��A� Design flow provided gpd
Plan: Date 1d'�-F - Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of
OF REPAIRS OR ALTERATIONS
rZ K " Date of Evaluation �?-' 2-77--
The undersigned agrees ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TTM 5 and
further agrees t he system in o ^.,,,s Certificate of CCompliaWnce has becu issued tb� the Board of Health.
Signed Date //'��`� %,yC
Inspections
No. COMMONWEALTII OE MASSACHUSETTS FEE 70
Board of Health, / AgM 4 UT MA.
CERTIE�CATE Of COMPLIANCE � d - ok
Description of Work: U Individual Component(s) Complete System f} S
The undersignertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded), Abandoned
by:
at
has been installed�p acc� ce with the,"
mss. 2110 CMR 15.00 (Title 5) a94,0 proved design plans/as-built plans relating to
application No. --��, d ��/T a . Approved Design Flow (gpd)
T Via.
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE
COMMONWEAUN Of MASSACHUSETTS
Board of Health, J , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissi n reby ted to; Construct(—) Repair( ) Upgrade(X) Abandon( ) an individual sewage disposal system
at 4 / A,t" �>4-4 as described in the application for
Disposal System Construction Permit �Z _
Provided: Construction shall be completed within three years of the date of this a All local condWons must be met.
Form 1255 Rev.5/96 A.M. Su co. cmdedw 7 Date // ��' / Board of Health ��