HomeMy WebLinkAboutHealth Permit # 2/16/2001 No. FEE
COIF MONWIALTH Of MASSAC14US ETTS
Board of Health, /V, PQ-TM AN NVI: f , MA.
APPLICATION FOR, DISPOSAL SAYS ThM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( Upgrade( Abandon( - ) 'Complete System ❑Individual Components
Location a�Lj 7` f ,. - � Owner's Name
Map/Parcel# Address
Lot# Telephone#
Installer's Name Designer's Name
Address Address q /}A
Telephone# Telephone# a`:� o y j l
Type of Building A'J S /e�'C> ve1-G/IV C, Lot Size sq.ft.
Dwelling-No.of Bedrooms 1-6--?�- 1-49"--t4 r t;_6, 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 ,I-aLa cja&! 244 Number of sheets J Revision Date
Title s r'st/5r-e U LY'er2szr' O) 5L/ L er,-\ e a7 dpi y Vic? rd �✓Ss�'�z 1
Description of Soil(s) Z e A/"
Soil Evaluator Form No. Name of Soil Evaluator /-> Date of Evaluation
r'i�'_-6 i'krld lea:
DESCRIPTION OF REPAIRS OR
� ALTERATIONS r ti/ e=T
� l
-1IAZ , FA—G%
A,L,
The undersigned agrees to' stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further ,to-n t to e e Ste op ation until a Certificate of Compliance has been issued by the Board of Health.
Signed ! Date CJ� 16 "Q/
Inspections
