HomeMy WebLinkAboutApp-Permit-Compliancea No. �J��C—�'O-022— FEE
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COMMONW 1LTH OF MASS CII, � TTSLU
Board of Health, `(flRMQ T4 — MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
JfA plic tion for a Permit to Construct() Re air Upgrade( )Abandon( )- ❑ Complete System kIndividual Components
oc
'on Li4cM15
Owner's Name 1 1:1 14A6 L. 00ioA
Map/Parcel# 3 199
Address qRosajoab 11 VAI es t go pw ``,A
Lot#
Telephone#
Installer's Name��t �� 6
Designer's Name
Address r53 j !E�;T MA6gpj5gAddress
Telephone# _ g -7
Telephone#
Type of Building j T-�( A -C, 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.
DESCRIPsTIOJN OF REPAIRSO-R
�f�
Name of Soil Evaluator
1—
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to the system in operation until a Certificate of Compliance has/been issued by the Board of Health.
Signed _ Date
Inspections
No. ia�C"^bG.- FEE �p
C®MMONWFA1LT14 OF MASSACHUSETTS Ck-�
Board of Health, Y89—M (K , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: .KIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired X, Upgraded,( ), Abandoned ( )
by: DEW(bG
at 40 'BR d LL LAo —
has been installed i accol dace with the p>i ovisions of 10 CMR 15.00 (Title 5) and ewe roved design plans/as-built plans relating to
application No. �L` +� ,G dated�. Approved Design Flow and
Installer" ( "&P7EUMQ4,L(!,
Designer: NSC Inspector: Date:��
The issuance of this permit shall not be construed as a guar 1111 that the system will function as designed.
No. F�O�(I%C- ��es't7��Q2 cp,p FEE J m 0Q
COMMONWEALTH OF MASSAC14USETTS
Board of Health, VAR -MOUTH i MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(N Upgrade( ) Abandon( ) an individual sewage disposal system
at 4--, i3RC72" 1a_ C—AME �n ` as described in the application for
Disposal System Construction Permit No. f �' dated'?--
Provided: Construction shall be completed within tl-ems of the date of this permit. All local conditions must, be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Charlestown, uta, Date?, J ! Board of Health "