HomeMy WebLinkAboutApp-Permit-Compliance• No-, 60tD c- f O-62-98 '
COMMONWEALTH OF MASSAC SET S
Board of Health, *r(jmD un4 , MA.
FEE ` S 600
APPLICATION FOS. � �®��L SYSTEM CONSTRUCTION �RMIT
Application for a Permit to Construct( ) Repair UpgradeO Abandon( - ❑ Complete System Individual Components
Location
(� e
p.
Owner's Name
Map/Parcel#
�� Y/
Address
Lot#
Telephone#
Installer's Name
C (
C
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Designer's Name
Address �,o,
w 110
Address
Telephone# Ci
1,100 ?- Coo
7 22--
Telephone#
Type of. Building le5Lot Size sq. ft.
Dwelling No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design flow Design flow provided r gpd
Plan: Date Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
A-ee`
DESC PTION OF REPAIRS OR ALTERATIONS ,, J C ` n . SQ C 400t<—
Cow
The un4
further
Signed
Inspec
to ' the abov ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
Y ae syst ration until a Certificate of Co�!mp ce has been issued by the Board of Health.
Date Cf �/ t��
No. iQ E D C" Ko--OZ-58 .FEE
C®�[�[®�1I.T���I1. /®� F 1�ASSAC��TSETTS
Board of Health, t N'Yi0,4_, MA.
1
�� CERTIFICATE Of COMPLIANCE
Description of Work: X11 Individual Component(s) ❑ Complete System Js
The undersigned hereby certify that the Sewage Disposal Syster; Constructed ( ), Repaired , Upgraded ( ), Abandoned ( )
by: (c.E CO . � � ��C 2017 � f (G0
I� L
at
has been installed in accotdapiQe with th310 CMR 15.00 (Title 5) and the roved design plans/as-built plans relating to
application No. � dated Approved Design Flow-�U�(gpd)
InstallerUu k Cc` t 1
Designer: --- Inspector:
The issuance of this permit shall not be construed as a gugp
�1 Date:
e that the system will function as designed.
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COMMONWEALTH OF M1 ASSAC1 iUS ETTS
Board of Health,VAR. �, f MA.
DISPOSAL SYSTEM �PNSTRUCTION PERMIT
Permission is hereb granted to; Construct( ) Re air( Upgrade( ) Abandon( ) an individual sewage disposal system
at , f70 -A- �� as described in the application for
Disposal System Construction Permit No. l dated���y 1
—/,z
�
Provided: Construction shall be completed within 4h��s o� I 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
FEE,
GZ 2 597