HomeMy WebLinkAboutApp-Permit-ComplianceCOMMONWEALTH OF MASSACHUS TTSd6t 133
Board of Health,u7- , MA. ,lf�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradeee) Abandon( - ❑ Complete System Individual Components
Location46 C12, e 74,i,'u O$C-G)
Owner's Nam ?rte <5 A()
Map/Parcel# 7
Address I?-
Lot# Z-3
Telephone#
Installer's Name3' �ji /� � b,
Designer's Name
p
Address 3'� h ,i d64v 0
Address -qA z;t 1';.v,0w , LlV
Telephone# -5767- Cl'Zb -Z- 2
Telephone# S -, T— ---
Type of Building AF -j
Dwelling - No. of Bedrooms
Other - Type of Building !
Other Fixtures OW f G7
Design Flow (min. required) gpd Calculated design flow
Plan: Date 7�2 t Number of sheets /
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
OF REPAIRS ORALTERATIONS -L/I�S7`4
/
7,1,c y f— -z- n /-/,, -
-
.ot Size sq. ft.
Garbage grinder( )
No. of persons Showers( ), Cafeteria ( )
Design flow provided 3lV 7 gpd
Revision Date
Date of Evaluation
,OC� /TQ /7TH e -R
i STQi � e.7�� GtU
The undersigned agree to install the abov�dibed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree t not place the tem ition until a Certificate of Compliance has been issued by the Board of Health.
Signed i Date %a 2 &
J
FEE I ST 00
.� CO�'I�' ONWEALTH OF MASSAC S ETT � 7�i
r- Board of Health,'!tJ 1 tt MA.
CERTIFICATE Of COMPLIANCE
0A
Description of Work;Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( )
by: of K J\WA�- C 05TIZO cit br�1
at + '? (; r i ( _?j AC 0 iii Z 0 A 1
has been installed in accordae with theprovisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. dated Approved Design Flow f(gpd) e.
Installer 'R C' C l)I (A -'-M P bet t,._ �M.149 ..GI
i Designer: !) A lb N t\5 oh.1 Inspector: _ Date:
The issuance of this permit shall not be construed as a guaranVthatlfhe system will function as designed.
No. Cjr. T,jc'9io 1 a9 2 � 11�j�1r � FEE S3. 00
COMMONWEALTH OF MASSACHUSETTS Lk-*
Board of Health, Y&2a 0 1 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade{ ) Abandon ( ) an individual sewage disposal system
at '2 61,P 7`4 , A, C'.'<-) as described in the application for
Disposal System Construction Permit No., dated
Provided: Construction shall be completed within t of the date of this peKmit Alllocalconditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date/0 Board of Health C-) cz-z8&