HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH Of MASSACHUSETTS
a Board of Health, )�MoLr , MA.
FEE
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APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade4,4/Abandon( ) - LI/Complete System ❑ Individual Components
Location ®
Owner's Name
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Map/Parcel# -
Address S'
Lot# 5
Telephone#
Installer's Namei / �S l
Designer's NamedN
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Address/9 4, t
Address
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Telephone#p Z
Telephone#
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Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms _lTZ , / Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) .3() gpd Calculated design flow Design flow provided 9 gpd
Plan: Date be;" /d Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator.� • f Date of Evaluation
DESCRIPTION OF REPAIRS • R ALTERATIONS P��°! / lJ� _ L✓ / v��L�
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 Dlace the systew
w in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
1
P N
Inspections 0
t
No. 6/ C."'14,-6 3 Z -ll �-4. Y J FEES
COMMONWEALTH Of MASSACHUSETTS P 1 L9c��
,ate MA. ��
Board of Health, ��� �,�` � �
CERTIFICATE OF COMPLIANCE �. r1ato A�
Description of Work: ❑ Individual Component(s) 116omplete System % ��
The undersigned her�eb certify/th/at the Sew,
by: /3
at ��6�� ✓�
has been installedri accgrd i¢e with the pr
application No. / �� dated �'
Installer
mal Sysrtem;%constructed ( ), Repaired ( ), UpgradedeAlianoned ( )
C Jy,�'T/.�2•�.�
of 10 CMR 15.00 (Title 5) an th ved design plans/as-built plans relating to
Approved Design Flow gpd)
Designer: Inspector: AZ Date:
The issuance of this permit shall not be construed as a guar . ee that the system will function as designed.
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y-� FEE $55OQ
e� COMMONWEAI.T1I OF MASSACHUSETTS JA 4r
Board of Health, �� ay ! Ti , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
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at t� /(/'-'Y ` e2
( ) Upgrade Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No./ ' -- ted 9
6 A 5,
Provided: Construction shall be completed within lh*tears of the date of this permit. All local conditions must be met.
�Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date —/ pard of Health
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