HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 VA fr/C-Aj 7--0-Z11✓ FEE V V
COMMONWEALTH Of MASSAC14USETTS
Board of Health, ) /6g QVT- t MA. t
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairv6pgrade( ) Abandon( ) - ❑ Complete System IIindividual Components
Location O y �,
Owner's Name
Map/Parcel# -7 -7 0
Address
Lot#
Telephone# J - 3 7)
Installer's Nam ,- --
Designer's Name '
Addresses
Address
Telephone# _ —
Telephone#
Type of Building iNxf Lot Size !ff�2CD,— sq. ft.
Dwelling - No. of Bedrooms Garbage grinder.(
Other Type of Building No. of persons Showers O, 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 41 Date of Evaluation
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 agrees to not to place the sys m in operation until a CertificateofCompliance has been issued by the Board of Health.
Signed /\ Date ? ! orb
N Fs �� FEE 5 ® b
COMMONWFALT14Of MASSACHUSETTS "fit�
a, Board of Health, _ Ap10 i%H MA. dz,
CERTIFICATE OF COMPLIANCE
Description of Work: llh Ividual Component(s) ❑ Complete System ,
N The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (Upgraded ( ), Abandone�(),
has been installed ' i accordance with theyrovisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated / ": Approved Design Flow (gpd)
Installer ~— '
Designer: Inspector: f✓i /5 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No• ) ` i t - ® _ "V° 1� CX�% FEE OiJ
COMMONWEALTH Of MASSACHUSETTS 40
Board of Health, Y6 9M63 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( )!Upgrade ( ) Abandon ( ) an individual sewage disposal system
at C") ZA i� ` ..;, �r l as described in the application for
Disposal System Construction Permit No. dated 9 4
Provided: Construction shall be completed within three years of the date of this pera it All local condig'ops must be met.
Form 1255 Rev. 5/96 A.M. Sulki ,Co. Charlestown, MA Date Cry l / / Board of Health i