HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE
COMMONWrALT14 OF MASSAC14USETTS
Board of Health,U� (ZWYJI I� , MA. � 5r
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair(N Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location a 9 L v e,e a ve i V.-
Owner's Name
Inspector: k i
Map/Parcel# l L J to
Address I LNC -1240
i y
Lot#
Telephone# _A "
Installer's Name (
Designer's Name
Address p p k _ �
Address C, rs 61)
/
Telephone# G. G yV p
Telephone# Soo . 3 _
goo
Type of Building R d" )"i -o / Lot Size �6' 13 S8 a 3 sq. ft.
Dwelling - No. of Bedrooms "/1%/ e C_ Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min/,eq 3-3 0 gpd Calculated design flow 33 0 Design flow provided 3� J gpd
Plan: Date i cs i L Number of sheets I Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
11," 16
Name of Soil Evaluator R ken v 4 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS ",,s r4 b,, �' J3 o) c 5-AA:C
4e.,, C o�,%d T.n r,, F °li`vw )6_2 t %skoc 11 `x alb �fi ID
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 system in operation until a Certificate of Compliance has been issued by the Board of health.
SignedDate / L
Inspections
) t c _— c - AG", <_"/l -7A
r
No. ! 2Z C®Nj MONWEAI.T14 OF MASSAC14USETTS
Board of Health, V VAP -MM , MA.
FEE.
CERTIFICATE OF COMPLIANCE
Description of Work: Vndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( Abandoned( )
by: 4'. A
at iw L,%1e _:�o - -
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer
Designer: �j'.!=
Inspector: k i
Date: Z
The issuance -of this
permit shall not becons
rued as a guarantee that the system will
function as designed.
No. 1 FEE
COMMONWEA1111®f MASSACHUSETTS
Board of Health, (1l , MA.
DISPOSAL SYSTEM'CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair() Upgrade( ) Abandon( ) an individual sewage disposal system
at e% (yr,00,,1 D %)Vr, as described in the application for
Disposal System Construction Permit No.dated
,�� ��`
Provided: Construction shall be completed within �r�bf "the"aate of this permi . l local conditions must be met.
Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date
/ �r