HomeMy WebLinkAboutApp-Permit-ComplianceNo. ' el-I5-4pd31 I '002)2 FEE �
6�Y' 1141
COMMONWEALT14 Of M ASSAC14USETTS
�' (f Board of Health, Yho 01A , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to ConstructVj Repair( ) Upgrade( ) Abandon() - '❑ Complete System ❑ Individual Components
Location
Owner's Name
Map/Parcel# 7�� Lo
Addressjo
Lot#
Telephone#
-,546 -
Installer's Name f
Designer's Name
BSC r
Address N
Address 314 9
P -+e2 k MC)
Telephone#4 , I
Telephone#
-7 b
Type of Building
Dwelling - No. of Bedroo
Other - Type of Building
No. of persons
Lot Size
sq. ft.
_ Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. �nd) gpd Calculated design flow Design flow provided gpd
Plan: Date & L f) Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 1 "' Z `- I'
DESCRIPTION OF REPAIRS OR ALTERATIONS �J� 1600 q a,l H 1 O A C'e Q. C,> H 1 e key i31 R26
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre n t to placeto operation until a Certificate of Com
Signed plifance has been issued by the Board of Health.
Date
Inspections
t
No. Vy 0 DC -15- (�0 031 . , FEE $ 5'5, DU
/ 7 -7 COMMONWEALTH OF MASSACHUSETTS
—44 316-7
Description of Work:
The undersiened het
by: )I
at
has been insta
Installer V/
Board`of iledUh; � N1 C� �-(}-; , MA.
c'ERhhcATE.0 tCOMPLIANCE
❑ Individual Compon�nt(s)-12--Complete'System
by certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrad ), Abandoned ( )
./ i -. r /-� i. , ,,-%
Designer:
The issuance of—this_nernut_sh
No.
vgith thi�prov1srods of310CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
dated /Z /y Approved Design Flow (gpd)
Inspector:
Date: /'-1 S
Lot -be construedAka_* raWee_that the system will function as designed.,
+ t j ex 4-0 00 FEE
COMMONWEALTH Of MASSACHUSETTS c, 3l b7
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construe Repair( ) UpgradelfAbandon( ) an individual sewage disposal system
at 3 6 �� a-C�-� as described in the application for
Disposal System Construction Permit No. 7?dated
Provided: Construction shall be complete/d wtthit%tet /wears o the dte of this permit/. �All`local
�conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA DatO' I—" / / �—Board of ealth
Id /5 ale, 1 (�Y%.> / x4 Y r,I /1 /,- /,, / ,1 I/��4,1/ 61,