HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1Z2 --:W z4/� �� n a � � FEE `� GC
UrP � - / COMMONWEALTH LTH ®f MASSACHUSETTS
YARPOCOTTH NEALT EPT. a
Board of Health, '
l�
APPLICATION FOR DISP®SALSS• LMT @TI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System L3 Individual Components
Location
Owner's Name
Map/Parcel#
Address
Lot#
f
Telephone#
Installer's Name _J�' fe Xl/7-,--"1,z -0 ,
Designer's Name
Address
Address
Telephone#
Su _ �, �' �- f "3 d
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 41— Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 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 REPAIRS ORALTERATIONS�`S/''/�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a on ce_the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ,;2-�
`Inspections
,/o
3 S ryL1
No. FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health,
CERTIFICT� ® C®M[��INC� 7U ('�c�rKlH<, rte,G'
Description of Work:._U-W&vidual Component(s) ElComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrad�, Abandoned ( )
by: 1 / i )'7- 'o—zl'Pfror r
has been installed in accor nce with the provisions of 310 CMR 15.00 (Title 5) and the ap oved design plans/as-built plans relating to
applicat� No. �U r , dated � —I�-/"D Approved Design Flo7w pd)
InstalJf•�f ��� r 7—
Designer: ��-�'`�'� �'y' ��...�;i..P-F. Inspector: Date:
The issuance of this permit shall not be construed as a guar�nteev at the system will function as designed.
No. (� / OG�/,%�'K �%`T FEE
COMMONWEALTH Of M ASSAC14USETTS
Board of Health, Y //l , MA.
DISPOSAL SYSTLM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade()-) Abandon( ) an individual sewage disposal system
ac", J A .1117 6 7.1 CSC G -- as described in the application for
Disposal System Construction Permit No. , dated.
Provided: Construction shall be completed within-t�ear sf the date of this ermit. All local conditions must be met.
Form 1111 Rev. 5/96 A.M. Sulkin Co. Charlestown, 11 Date �2 -//- //0 Board of Health