HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60"C-1-7-338?-
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0" C -i -7338? -7 Ol d C®M RW'(!kLsH I S- �A S'1TV>f-1
Board of Health, Y/ VI (i LM MA. IF
APPLICATION FOM, DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE '
C" to
Application for Permit to Construct( ) Repair( ) Upgrade(-)-<bandonO ❑ Complete System-21,-dividual Components
Location %�
Owner's Name
Map/Parcel#
Address
Lot#
Telephone# -7
Installer's Name
Designer's NameL%ZY%
Addressn
All
Address 72.7
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms C2 Garbage grinder ( }
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) o20 6% gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
f n
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr es to not to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed = Date
Inspections
No { FEE17— .
®}�'I�9[ONITII OF MASS14JSKTJ1
.� Board of Health, V42.W -)TN MA. c'f /
CERTIFICATE Of COMPLIANCE
Description of Work: 1vidual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (r,�andoned ( )
by:N t �7 - a9 ' �
at �� t� t ./ 4t 'A
has been installed in accordance with the
application No. 7_.. (0dated
/
Installer / I 11i,F -4 e
C
Designer: 42e�&04 444
The issuance of this: p WA not be c<
of 310'CMRr15.00 (Title 5)and th approved design plans/as-built plans relating to
�. Approved Design Flo 4h
Date: %' f'Z ,%
T—T- F
as a guffadiee that the system will function as designed.
CIO
No. 6Q .g Dc - —339, Z»i5, t _ PA . C-ff - -0 Wr FEE .F
COMMONWEALTH EALTH O 1' ASSACl�t SETT
Board (f Health, YBl DT MA.
DISPOSAL SYSTEM[ (CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade, -.a -''Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. fO , dated
Provided: Construction shall be completed within.thr ears o- f the date'of this per it. All local co didons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Cha lestown, MA Date-�� Board of Health.