HomeMy WebLinkAboutApp-Permit-ComplianceNo -600C —0— 0213(0
P,LM4S--0011-79
6/7 2,>- 17 C ONWFALT11 OF MASSACHUSET'l
Boas d of �lealtli, y�i'f li MA.
ATION F® DISPOSAL SYST CONSTRUC
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Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete Sys
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Location
Owner's Name
Map/Parcel#
Lot#
Address r
Telephone#
Installer's Name
5 Designer's Name S p
Address/ /
'LV6/4_1Telephone#
Address'
Telephone#
b
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. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS AleaJ % fi y
The undersigned agrees to install the above de cribed Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to pq to place the eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
i
Inspections H
_ eA
No.
C®MMONwEA LTu OF 1 SACIIUSETT-
Board of Heald i, MA. —/7
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 1l(Complete System
The under ' neq hereby ce t that the Sewage Disposal System; Constructed ( ), Repaired (�), Upgraded ( ), Abandoned
by: S r-_-eT)C �.
at
has been installed'n accordancc-e�with the rovisions of 31.0 CMR 15.00 (Title 5) an th a proved design plans/as.-built plans relating to
application No. ". /, da ed `� !7 Approved Desigu'Flow (gpd).,
Installer ; , h r'
Designer: 1,J; SGS .5 - Inspector:. Date:
The issuance of t� permit shall not be construed as a guarana that the system will function as designed.
COMMONWEA LTH OF MASSACHUSETTS
Board of Health, Y%3 -aft lm4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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5
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
atm 1> as described in the application for
Disposal System Construction Permit No.'� 41 dated
Provided: Construction shall be completed within sof tFiate of this perixi Vocal com ition s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MR+ Date
m , / � r BOa d of Health
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