HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWFALT14 OF MASSAC14USETTS ��Q
`6"AR-`." s eg � H HEALTH DEPT. % 4JOx
Board of Health, 144 i I € T E ^fit , MA.
APPLICATION FOP, DISP®S& Mf t WCTION PERMIT
Application for a Permit to Construct( ) Repair (11-*U*`pgrade ( ) Abandon( ) - ❑ Complete SystemCCi vidual Components
Location /� /YJ O A/ LF*4 A v A,
Owner's Name � £ O r[' � � s'l/ &V
Map/Parcel#
Ila Z l
Address £ "ti A- ,r 00,,?t
Lot#
Telephone# S'G ? '37.6
Installer's Name
0-,4,v (a
Designer's Name
Address e-3 541
A- r-
_ Y Address
Telephone# rs,o
7 S' - ;P- �` ri.
Telephone#
Type of Building
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.
10
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Zl z- T L T 7- F
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire to not to place the system in o ration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date G L'
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
FEE /Y,
Description of Work: &1ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (;'Upgraded ( ), Abandoned ( )
by: -,4 dd// lL�7j 0 X.- C G' 3 .5- `' /x, 5� Gr,
at /a 2-, O// 1r KA w L-A- Y1.19 4 47/P,—
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 /N� 5-)-/, dated �4C11 Z Approved Design Flow (gpd)
Installer
Inspector:
Date: 12- -,f C) -
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
C®MM®NWEIET14 OF MASSAC14 SETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
d(
Permission is hereby granted to; Construct ( ) Repair ( -'J�Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 1�2 6 //7/ Z 1A A- ,J as described in the application for
Disposal System Construction Permit No. G� �-� , dated
Provided: Construction shall be completed within th of the date of thisyorMit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M.Sulkin Co. Boston, MA Date /2 ` I `� '`Board of Health
i