HomeMy WebLinkAboutApp-Permit-ComplianceNo." Ocd(o -06 g -2� �� �¢� ! ���1� � � FEE 5 7 e fV
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COMMONWE ALT14 OF MASSAC114 TTS dvv-03 z/8 3
Z Board of Health, _A -le wl� t� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
0 Ap Il
ication for a Permit to Construct( ) Repair( ) Upgradekj"AbandonO - ❑ Complete System Individual Components
J11cation lit; V i ✓T Owner's Name 11,L,
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 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
DESCFJPTION OF REPAIRS
The undersigned agrees to install�My,
des be Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to I the er n untila Certificate of Co pliance h been issued by the Board of Health.
Signed Date vim+
Inspections
n
No. 0 41) C - ((0_0 (0S K�l� / '` t/ I . FEE
COMMONWILALT14 OF MASSACHUSETTS; k./u, Lk Cc 210
Board of Health, A f�,i �! to (1T F MA. p� kol�^-•}�j
CERTIFICATE Of COMPLIANCE (ice
Description of Work: .9Wdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradeAbandoned ( )
by: F. � ( (� 1. h.l
at
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. 40. dated 7 I Approved Design Flow (gpd)
Installer
'Designer: IT, W%Ji5 ''4"" M0C• Inspector: Date: �'°"",�A7 —,14
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. C) WA) i 16 -016 C 06elv( CA (o) 5 w C FEE
16 . G� COMMONWEALTH Off' MASSAC14USETTS - 634 �
Board of Health, VAR.kOU TY MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairs ) Upgrade,(,'Abandon ( ) an individual sewage disposal system
at f 1 Eyer ; rz_ 5:5N SM. as described in the application for
Disposal System Construction Permit No. //10 dated �—)l /, ,
Provided: Construction shall be completed withirLth ee_ueax*rof the date of this perm l local conditions must be met.
Form 1255 Rev: 5196 A.M. Sulkin Co. Charlestown, MA Date 9--.2-7 - Board of Health i
r
Map/Parcel#
33 3
Address i KA
Lot#
Telephone# 508 4 f 11 1-7
Installer's Name
W 1L
.lav
Designer's Name
Address ikAggriDN
NIS
Address e LN E fi%MFVT14 .
Telephone#
Telephone#Soov 1,54o 2534
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 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
DESCFJPTION OF REPAIRS
The undersigned agrees to install�My,
des be Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to I the er n untila Certificate of Co pliance h been issued by the Board of Health.
Signed Date vim+
Inspections
n
No. 0 41) C - ((0_0 (0S K�l� / '` t/ I . FEE
COMMONWILALT14 OF MASSACHUSETTS; k./u, Lk Cc 210
Board of Health, A f�,i �! to (1T F MA. p� kol�^-•}�j
CERTIFICATE Of COMPLIANCE (ice
Description of Work: .9Wdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradeAbandoned ( )
by: F. � ( (� 1. h.l
at
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. 40. dated 7 I Approved Design Flow (gpd)
Installer
'Designer: IT, W%Ji5 ''4"" M0C• Inspector: Date: �'°"",�A7 —,14
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. C) WA) i 16 -016 C 06elv( CA (o) 5 w C FEE
16 . G� COMMONWEALTH Off' MASSAC14USETTS - 634 �
Board of Health, VAR.kOU TY MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repairs ) Upgrade,(,'Abandon ( ) an individual sewage disposal system
at f 1 Eyer ; rz_ 5:5N SM. as described in the application for
Disposal System Construction Permit No. //10 dated �—)l /, ,
Provided: Construction shall be completed withirLth ee_ueax*rof the date of this perm l local conditions must be met.
Form 1255 Rev: 5196 A.M. Sulkin Co. Charlestown, MA Date 9--.2-7 - Board of Health i
r