HomeMy WebLinkAboutApp-Permit-ComplianceNo L2>oikDOW07S2.(//jlJs �" 6 / � � FEE ,OO
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Board of Health- , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
plication fora Permit to Construct( ) Repair Upgrade( ) Abandon O - ❑ Complete System aldividual Components
Location i_ �,`
Owner's Name
Map/Parcel#
�y� � Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address
Address
Telephone# ou 0
Telephone#
Type of Building
Dwelling - No, of Bedrooms
Other - Type of Building _
Lot Size
sq. ft.
Garbage grinder ( )
No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ::�2 470 gpd Calculated design flow Design flow provided _ 7 gpd
Plait: Date. Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
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 is place the system in operation until a Certificate off Compliance has been issued by the Board of Health.
Signed ��� Date J _ lz)„' Iz
Inspections 0 -
No.P^iON gc--�&��(Q��4//�4FEE 00
CO�"I�'l[ON�IT1I OFMASSACHUSETTS,0.1�13�tS- r
Board of Health, YAeA0o, A04 , MA•��% 02-0-/
CERTIFICATE OF COMPLIANCE 7
Description of Work: II dividual Component(s) ❑ Complete System
The undersigned hereby certify Pat the Sewage pisposal System; onstructed ( ),Repaired( ), Upgraded ( ), A' bandoned ( )
at c-
has been installed in accordan e with the rovisions of 10 CMR 15.00 (Title 5) and t ca roved design plans/as-built plans relating to
application No. dated � � 1 % . Approved Design Flow(gpd)
-
Instalier r ! f
Designer: Inspector: / - Date:' C
The issuance of this permit shall not be construed as a guarantee th t the system will function as designed.
No.jA A3D( boserm FEE i 5S_ +
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YA-(Zh d U -r -W M�
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Co struct( ) Repair (t-)/ Upgrade( ) Abandon( ) an individual sewage disposal system
at
`7 �S j l✓ ,d� e as described in the application for Disposal System Construction Permit No.//1 �: dated
Provided: Construction shall be completed within th4g&:� of the date of this permit. All local conditions must be met.
6�5
Form 1255 Rev. 5/96 A.M. S,u{lkin Co. Charlestown, MA Date "-/ Board of Health /�