HomeMy WebLinkAboutApp-Permit-ComplianceNo. � 1/✓ �t /�-'"'.��'l FEE'-�
COMMONWEALTH OF MASSACHUSETTS ck+5q rZ
Board of health, Y 0 , mA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION -RMIT
A lication for a Permit to Construct( ) Repair(upgradeO Abandon( El Complete System Individual Components
Location
^(y
�C Owner's Name C:rOiND
Map/Parcel#
. ✓
Address
Lot#
Telephone#
Installer's Namener's
Name
Address_
�'
l Cr L Address
Telephone# 0$1f
2
Z7� 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, required) 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
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersi d gree :install ovedes vdual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr t no loperation until a Certificate of Cm_p,�upce has been issued by the Board of Health.
Signed Date ��-7G `l/
Inspections
No. o � � ' FFE
COMMONWEALTH OF MASSACHUSETTS ov-,
l )%® � °
Board of Health, ,
CERTIFICATE OF COMPLIANCE
Description of Work:. 4111d vidual Component(s) ❑ Complete System
The undersigned herebyce tify that the Sewage Disposal System; Constructed ( ), Repaired (graded ( ), Abandoned ( }
by: %t
has been installed
application No.
Installer A 5
with the rovis ons 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated '_-�� . Approved Design Flow ---- (gpd)
Designer: Inspector: 4� ( j( VZ G' Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ` G:7J ( A -P
COMMONWEALTH Of MASSACHUSETTS
Permission is hereby
at � CC)
FEE
Board of Health, 0 t1T1-�
DISPOSAL SYSTEM C�OSTRUCTIONPERMIT
to; Construct( ) Repair( V Upgrade ( ) Abandon ( ) an individual sewage disposal system
DisposalSystem Construction Permit No.
dated
r
as described inthe application for
Provided: Construction shall be completed within three years of the date of this permit`Heal conditions must be met.
Farm 1255 Rev.5/96 A.M. Sulkin Co. Charlestown MA Date _/Board of Health {l