HomeMy WebLinkAboutApp-Permit-ComplianceNo. % FEE'—-�
COMMONWEALTH OF MASSACHUSETTS ejc � 717
Board of Health,��/ 9l 1�'�" , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTr PERMIT
Application fora Permit to Construct ORepair'(mo1Pgrade Abandon ❑ Compfete S stem ❑Indvidual Components
Location
FEE r
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Owner's Name v
Map/Par
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CERTIFICATE Of COMPLIANCE
Address ��it JL t�
Lot#
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired G,Upgraded ( ), Abau
Telephone#
Installer's Named
g
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Designer's Name
Address
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Address
Telephone#
The issuance of this permit shall not be construed as a guargf�tee that the system will function as designed.
Telephone#
Type of Building - r ��� Lot Size sq. ft.
Dwelling- No. of Bedrooms Garbage grinder 4410
Other -Type of Building big, 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 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agr o " tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to• o o pia the tgdon until Certificate of Compliat►ce has been issued by the Board of Health.
Signed Date r�
Inspections
NoAn=1r�'( s� �t� .d
FEE r
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y A•R007"
CERTIFICATE Of COMPLIANCE
Description of Work: -Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired G,Upgraded ( ), Abau
oned ( )`
at ZMV Ak,
has been installed �u `ccordan e with the provis' of,3'10 CM& 15.00 (Title 5) and the approved design plans/as-built plans relating to
No. 4 dated 4 6 1^+ts Approved Design Flow ""� (gpd)
application , .
Installer
;p� �
Designer: Inspector: t ({ • : rJ r
The issuance of this permit shall not be construed as a guargf�tee that the system will function as designed.
No., �iP ` %
FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, -M 0 1��4 , Mfl.
DISPOSAL. SYSTEM CONSTRUCTION - HERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at i e. "s'�V �— % - as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of ;M�Z
conditions must be met.
Form 1256 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date /_'111 - 0/1 r 4oard of Health 7