HomeMy WebLinkAboutApp-Permit-ComplianceNo.—4
COMMONWLAQU
Board of Health, 1146 ROUTE 28
APPLICATION FOR DISP®WM?RN CTI®N PERMIT
FEE J J 4 V
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Application for a Permit to Construct( ) Repair( ) UpgradeV-26andon() - ❑ Complete Systemea I dividual Components
Location.� IV .11 /III,���
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Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
3
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 �Q 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 REP RS qR ALTERATIONIS
a -t �dic
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
x further agrees to n t to lace the t in operation until a Certificate of om liance has been issued by the Board of Health. 110
Signed v LA� Date st
Inspections
i
No. /di v c.o
FEE
COMMONWEALTH OFMASSACHUSETTS-- �S ,
Board of Health, MA.
CERTIFICATE Of COMPLIANCE r
Description of Work:91Itfdividual Component(s) U Complete System
The undersi n d reby cer ' at the Sewag Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned)
at V 5
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) a d_the a roved design plans/as-built plans relating to
application No �B —12-,F- , da�tted� S11-16 . Approved Design Floe pd)
Installer
Designer: Inspector: Date: Cq G
The issuance of this permit slydll not be construed as a guarantee that the system will function as designed.
No. ID /awG6l FEE C,G/CJ
COMMONWEALTH Of MXSSACHUSETTS
Board of Health, , MA.
DISPOSAL SYST eCONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (X Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. //0 , dated
4�
Provided: Construction shall be completed withilnr`t�i ee 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 VV Board of HealthL-
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