HomeMy WebLinkAboutApp-Permit-ComplianceNo. 4� FEE
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COMMONWEALTH OF MASSAC14USETTS �
WEPT.
Board of Health, 6 i�il1 fT. r 8 ,
APPLICATION FOR DISPOSAL :OMMS TION PERMIT
Application for a Permit to Construct( ) Repair()<Upgrade( ) Abandon( ) - ❑ Complete System /Individual Components
Location ' e`
Owner's Name
Map/Parcel# G
Address
Lot#
Telephone# ROP
Installer's Name `TJlaf �lty'��`E��'
Designer's Name
Address 63 4:::� �% ��� �y ,
Address
Telephone# S—o co :pr;7 ,3`' 50.P -a>'
Telephone#
Type of Building `- /(i �-e Lot Size
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS�l/�G
r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to lace a system in operation until a Certificate of Com 1' ce been issued by the Board of Health.
Signed Date cam— i9 6
Inspections
No. / b ` FEE J
Ei0*b C.- tb -1d681 COMMONWEALT14 Of MASSACHUSETTS
Board of Health 1��f 0?,19;r ® a.;P* ; MA.
CERTIFICATE Of COMPLIANCE
Description of Work: /Individual Component(s) ❑ Complete System L i
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( )
by: L�e i''%% Gr ��o G� G/i�" .!' t¢d-.�� f P -1—e .
has been installed in accordance with the provisiovis of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.I C. 14 3 , dated !tZ 01 «+ . Approved Design Flow (gpd)
Installer
r -
Designer: fY,% Inspector: Date: J l
e.
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 1 T ( FEE
Pro v c -t - t b 9
COMMONWEALTH OF MASSACHUSETTS C (<Z_
Board of Health, �1r�/%lC�, MA. ' ; ss z i
DISPOSAL SYSTEM CONSTRUCTION PERMIT � � r.v
Permission is hereby granted to; Construct( ) Repair('Upgrade ( ) Abandon( ) an individual sewage disposal system
at e51 r(s, 61ro.i'e J, �� as described in the application for
Disposal System Construction Permit No. 16- G 3 , dated G 3
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health(