HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60 OC— I9—M 5-7 0Ci � FEE 4 65 000
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COMMONWEALTH OF MASSACHUSETTS
%�fr/SBoara of Health, )LAK,1m MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ompiete System ❑ Individual Components.
Location 4-1
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Owner's Name USu rn
Map/Parcel# 151S
Address ' 1
Lot#
Telephone#
Installer's Name
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Designer's Name V1 1A i
Address
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Address I
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Telephone#
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Telephone# g, . i
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures V.
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 Date of Evaluation
ASCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with theprovisions of TITLE 5 and
further agr s to not to Alace thj,system * operation until Certificate of Vomipliance has been issued by the Board of Health..
Signed Date N 1 19
Inspections
No. c) i� FEE' r
COMMONWEALTH OF MASSACHUSETTS
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Ak Board of Health, f-ttiO tom{
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded .Abandoned( )
has been installe 1' i a ordance with the provi ions of 10 CMR 15.00 (Title 5) and th proved design plans/as-built plans relatirog to
application No. (( �` dated t �� ~,� Approved Design Flow (gpd)
Installer 1 f. 1 !c e.' i ; ,tr`I ! i Y ! � t fil v i
Designer: i 1C:tniii ; (' 1irri il•1(!': ?-411Ii Inspector: Date: T�
The issuance of this permit shall not be:constrixed as a guarantee that the system will function as designed.
No., -4
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COMMONWEALTH OF MASSACHUSETTS j- -
Board of Health,, Aem O LM!
DISPOSAL SYSTEM CONSTRUCTION _ PERMIT
Permissij= is herebygranted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at � �l U Y C •t'E : / as described in the application for
Disposal System Construction Permit No. •�-/ , dated_
Provided: Construction shall be completed within tiwe4 f"the date of this permit. All local -conditions must be met.
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Form 1255 Rev. 5/96' A. . Sulkin Co. Charlestown, MA Date / .J ! / Board of Health ( '
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