HomeMy WebLinkAboutApp-Permit-ComplianceNo. f fp FEE
COMMONWEALTH OF MASSACHUSETTS c q(sb
Board of Health, YA �-V^""t-�-. , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct(' Repair( ) Upgrade( ) Abandon( )-AComplete System ❑ Individual Components
Location %
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Owner's Name
Map/Parcel#
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Address 4S Wim: c✓t/�q rY►.rr!}� r^1
Lot#
Telephone#
Installer's Name b,�d
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Designer's Name
Address �`
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Addresst(A (2;(- 1 < 1 1
Telephone# (�, �
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Telephone# � "]�y (a► Z (i,
Type of Building Re-s,t A -i cx 1 Lot Size 1 d sq. ft.
IF
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building tj in No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures Njjv�
Design Flow (min. red)33o gpd Calculated design flow -3 a Design flow provided 3 y 8 gpd
Plan: Date ! 11S 1 1(o Number of sheets Revision Date �r
Title t -c 1'[ G K S` ts� 7 k t ""
Description of Soil(s) 72-1 4 Sq -4
Soil Evaluator Form No. Name of Soil Evaluator 9W Nt�— K tA- Date of Evaluation
SC4 154-,
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
fur er a to not to place the system in operation until a CeTDae
'a of Compliance' �has been issued by the Board of Health.
gned /" �/�
Inspections
No. L& 1°llM TltJt Of A'1.1t7t�1J ETTS FEE
Board of Health, YG e " i -t CEJ - -- L , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) . Complete System
The under si ned11hereby ertify that t e Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded¢'f,�Abandoned ( )
by:
at ��.�cf 4v civ d Gt} cn.y
Gu (1-(4,`Y r7
has been installed j' ac or ance wit the provisions of 310 CMR 15.00 (Title 5) and th pproved design plans/as-built plans relating to
application No. r dated ` //- Approved Design Flow �� (gpd)
Installer
Designer: Z97914&1-11,$ S Inspector: � r�: Date: 1 (G
The issuance of this permit all not be construed as a guarantee that the system will function as designed.
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No. %" — �YYG�lv��+ FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, y6kr" c -v 4 -L-1 , MA.
DISPOSAL SYSTEMS CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(,) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 15- 100, 4 W a1rd1 as described in the application for
Disposal System Construction Permit No. -�' �, dated 2- .-/ j' 1-,6
Provided: Construction shall be completed within tkxrs of the date of this per. it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date ` ` - � Board of Health