HomeMy WebLinkAboutApp-Permit-ComplianceNo, FEES(✓ lJ
COIF MONWEALTHIF MASSA HUSETTS e�0
��+3�601
IV
Board of Health, MA. ,
a
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade K) Abandon( ) Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Name
Address t zf
Address r
Telephone#..-
Telephone# -^
r
Type of Building Lot Size dr (o� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( }
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design flow iid Design flow provided gpd
Plan: Date j�- ! "�� Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undaeenot
rees to install th bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further t e em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. ell()0 C• P 0 FEE 4 it
COMMONWEALTH OF MASSACHUSETTS
A Board of Health,� ® U , MA.
CERTIFICA Of COMPLIANCEDescription of Work: ❑ Individual Component(s) O omplete System
The ut �edereb certify that the Sewage Disposal System; 'Constructed ( ), Repaired ( ), Upgraded, Abandoned(
by:
at
has been'ims lled in accor �n/.ce with the provisions of 310 CMR 15.00 (Title 5) and the a :roved design plans/as-built plans relating to
application No. / �i dated 7-1 `" / . Approved Design Flow �� (gpd)
Installers
Designer: ;NXM_ i e—i..i As Inspector:r thi ifs �, ('��il.�f � Date:
The issuance of this permit shall not be construed as a guarantee that e system will function as designed.
7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, {Z Q , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
------------
FEE $55,00
s t
119
j
Permission is hereby a ted to; Const ) Repair( ) Upgrade ( Abandon( ) an individual sewage disposal system
at " /i'' fr�P®l i�"��- ���� t/� t as described in the application for
Disposal System Construction Permit No. - i ��s , dated
Provided: Construction shall be completed within thr f5e date of this pernn All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date % �/� ?Board of Health