HomeMy WebLinkAboutApp-Permit-ComplianceNo. / �' O O e / FEE
COMMONWEALTH Of MASSAC14USETTS
Board ofHealth,
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (PfAbandon( ) - ❑ Complete System 0hdividual Components
Location -7,
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Address
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•Telephone#
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Installer's Name
r/ `y ALF.
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L i r
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) 536 gpd Calculated design flow
Plan: Date Number of sheets
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ) , Cafeteria ( )
Design flow provided �/ S� gpd
Revision Date
Title
Description ofSoil(s)i
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
1
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 system in oper 'on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 7-3L//V
Inspections
_ No. � � FEE
COMMON LT14 Of MASSACHUSETTS
Board of Health, )/G O VT" , AL4.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constricted ( ), Repaired ( ), Upgraded (✓), Abandoned ( )
at /
has been installed' actor a with the provisions of 310 CMR 15.00 (Title ) and thea proved design plans/as-built plans relating to
application No. / /J dated __7 % Approved Design Flow (gpd)
Installer
Designer: Inspector: l�(�,` / Date:
The issuance of this permit shall not be Vnstrued as a guarantee that the system will function as designed.
No.C` Lia' " ' � LC �'.L� FEE S "� •' G� �-�'
COMMONWEALTH Of MASSACHUSETTS g f '� (� 2- C f'
Board of Health, yA (ZMO UTI -
DISPOSAL `SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(✓) Abandon( ) an individual sewage disposal system
at ! l _ as described in the application for
Disposal System Construction Permit No.�, dated _7' i�;1 `>
Provided: Construction shall be completed within`ihears of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date —
Board of Health (/ "