HomeMy WebLinkAboutApp-Permit-ComplianceNo. l tel- �fG7 F' EE
COMM6M. I. MI✓ SA( SELIJ T
f Board of Health, PrL h/I d, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
_ A plication for a Permit to Construct( epai Upgrade( ) Abandon( - ❑ Complete System ❑ Individual Components
Location
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Owner's Name L
Map/Parcel#
300
Address Zr r S
Lot#
Telephone# go
Installer's Name
Designer's Name
Address 3 C
Address
Telephone#
,� . — Z
Telephone#
Type of Building '3-t°_5
Dwelling - No. of Bedrooms _
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF
The undersign d
further agrees o l
Signed
Inspections
_1 r
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
OR ALTERATIONS
_ (., " 1� �
Lot Size sq. ft.
Wf Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
tce the system ' peration until a Certificate of Compliance has been issued by the Board of Health.
Date
FEE 5 -
�^ C®MMON U'1' FALT14 Of SSAC141JSETTS
Boaof 4alth, YA%L.�1i1 O i { MA.
�
rd
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Indh4dual�Component(s) ❑ Complete System e /
The undersigned hereby certify that the Sewage Disposal System; Cons tcted ( ), epaire ), Upgra ed ( ), Abandoned ( )
by:
at r 'fie o D
has been installed in accordance with the provision of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans,relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: Inspector:
Date: �- L
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. FEE sVi
COMMONWEALTH Of MASSACHUSETTS ctc � a.6q
Board of Health, YA F -M D V-1-14
5,
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Re airDv�
Upgrade( ) Abandon( ) an individual sewage disposal system
at �� ?a, U�oO lei l� �� N�Lc� �A& M as described in the application for
Disposal System Construction Permit No./ 1' �' .,dated Ll .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met..
Form 1255 Rev. 5/96 A.M. Sulkio Co. Chatlestown, MA Date S Board of Health y ��