HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUSETTS7`
Board of Health, _ y 3�/1pltTld , MA.
r APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Allication for a Permit to Construct( ) Repair( ) Upgrad ) Abandon O - 5 -Complete System ❑ Individual Components
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ocation
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Owner's Name
ap/Parcel#
Address
Lot#
Telephone#
Installer's Na
Designer's Name
Address 'Z
Address
Telephone# v ^
Telephone#
Type of Building Lot.size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. require) 0 gpd Calculated design flow Design flow provided S!Y 2 gpd
Plan: Date �2 ` Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
The undersigned agr s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree no to plac a syste in operation until a Certificate ofm liahce has been issued by the Board of Health.
Signed Date ZZ��-2
COMMONWEALTH Of MASSACHUSETTS
Board of Health, V" -I 0A 0 ft"1�6 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Cons`tr`ucted ( ), Repaired ( ), Upgraded Abandoned ( )
byi
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has been installed in
application No. %
Installer
with therovisions of 310 CMR 15.00 (Title 5) and the pproved design plans/as-built plans relating to
dated i-47. Approved Design Flow 4 (gpd) /? f
Designer:lw�s�r�i� fi'� �� Inspector: Date: e7
The issuance of this permit shall not be construed as a guarVtke that the system will function as designed.
No. zap— U " FEE C'
I COMMONWEALTH OF MASSACHUSETTS
Board (f Health,YA h i n:} MA.
DISPOSAL S1'STEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ,,.)' Abandon( ) an individual sewage disposal system
at -,Ae- CL% 13U4X-kRMA �gK &41 as described in the application for
Disposal System Construction Permit No. / % ✓tai �7' , dated -,7-'' -7.
Provided: Construction shall be completed within three years of the date of this perm it. All local conditions must be met.
Form 1255' Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date " ' / Board of Health rt
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