HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,BO►�c^ � 1 F►�'`G'�"V�I� L � FEE4110. Q�D
l 9COMMONWEALTH
Board of Health, ` `f Al2M 3 QT-H , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to ConstructwRepair( ) Upgrade( ) Abandon( ) J2'Complete System 0 Individual Components
Location
Owner's Name
Map/Parcel# •-- 5
Address _
Lot#
Telephone#
Installer's Name
Designer's NameERr'
Address
Address 0.
� -
Telephone#
Telephone#'
Type of Building Lot Size I-0- 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 CH l.`1 12) Number of sheets Revision Date
Title
Description ofSoil (s) 1, 1&`-` 1�
Soil Evaluator Form No. Name of Soil Evalt
OF REPAIRS OR ALTERATIONS
of Evaluation
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 �cehe system ' operatipn until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
L 1, �.L6& - . .�
Inspections
,
No.71
EE 10
n COMMONWEALTH I�TH OF MASSACIIUS�TT
t Board of Health, '/A9,M6QT14
CEIITIFI� E Of COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System
The undersigned lZereby certify that the Sewage Disposal System; Constructed ( /,Rpaired ( ), Upgraded ( ) > Abandoned ( }
by: d1
at ;LA
has been installed in accordance with the provisions of 3.1,0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating.to
application No., / ".� �*" dated %� ' " 1&..',Approved Design Flow:� (gpd)
11 Installer 1A ON
°N 1 nil i 16 4
Designer:i'�(rsd(1)a`ctAabectoi:_ �_. tr' f3G' llate:JG /'
The issuance of this,permit shall not be construed as a guard ee that the system will function as designed.
—P FEE 0 0 , 00
COMMONWEALTH Of MASSACHUSETTS
--�--'":: Board of Health,,MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(X Repair( ) Upgrade( ) Abandon( ) an individual;, sewage disposal system
at
as described in. the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within t4=4W0(Vl'i"e date of this pert, it.� All local con itions must be met.
h r
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date �U f IfBoard of Health
:01