HomeMy WebLinkAboutApp-Permit-ComplianceNo. QW FEE
COMMONWEALTH OF MASSACHUSETTS 11h 711,
YPkR, 0UTH HEALTH DIF -l'.
Board of Health,1jzi L,�"� p3 MA.
APPLICATION FOP, DISPMATTRYNTOSUCTION PERMIT
Application for a Permit to Construct() Repair() Upgrade
^Abandon() - ❑ Complete System ❑ Individual Components
Location f
C tvt J &" o' LA
Owner's Name
Map/Parcel#
l67 ��
Address
Lot#
Telephone# S �% �" ?,;z
Installer's Name
z— S. �
Designer's Name
Address
A /+&/
Address P. 0.a-c� /
Telephone#
Telephone# 3 5,�- f S
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date ftV �G ,O�"--/ Number of sheets Revision Date
Title
Description of Soil(s) S,?t' Ste' � Lir
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S-4 S e
The undersigned a es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t o ce the t peration until a Certificate of Compliant has been issued by the Board of Health.
Signed Date
Inspections
No.
CP. MMON LT14 OF MASSACHUSETTS
Board of Health, r/` wt c -� 1 '� ; MA.
CERTIFICAA Of COMPLIANCE
FEE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
at
has been installed in accordance with the rovi ons d a o .310 CMR 15.00 (Title 5) anproved design plans/as-built plans relating to
application No. G , dated Approved Design Flow (gpd)
Installer I_. I • (3) c %%.P. rc
Designer: SU e P // y i Inspector: Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
r
No—o6-16 ,/,-, S
COMMONWEALTH OF MASSAC14USETTS
Board of Health, 1 7� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE / UV
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
' G
Disposal System Construction Permit No./ a6 Ir63 ,dated
Provided: Construction shall be completed within 4l/// /� �he date of this l local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 0 Board of Health V