HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60 Oc (? " Z3 6 J e fl 7,f h Itj Al, e,6i, - FEE SS,OD
COMMONWEALTH Of MASSACHUSETTS
Board of Health, !P a mA , MA.
APPLICATION FOP DI �i�L SYSTEM ST CONSTRUCTION MIT
Application for a Permit to Construct( ) Repair( UpgradeO Abandon( Ll Complete System Individual Components
Location 20
ico
Owner's Name n<T A,2
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name C
ti .S(�
C��(1
Designer's Name.
Address ,
lr�„/_ CjtJ
pZ
Address
Telephone# 5-0.9
?,V0'z560 j'%
zw 719
1 Telephone#
Type of Building A 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
DESCRIPTION FREPAIRSpp��ALTERATIONS P G� J)— COd a( -e
o e Gni i'�il1 0 a
i✓
The undersigne e s o install above de In -Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o t to on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date___
Inspections
No %ky- - 1
COMMONWEALTH EALTH O MASSACHUSETTSFEE "f.
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: /Individual Component(s) ❑ Complete System of`,�Oal-�
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ,Upgraded O, Abandoned( }
by: l u�:P,{ cc)
-2
if�ieOP
at iC� , 14(;tfa
has been installed in accor ance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated , "� �1� _!� Approved Design Flow (gpd)
Installer 1,10
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guareeat the system will functio as designed.
No. ,3 u�bc- 1 7 — 25�(n (4 r 610b 5Ei" 1 ► C` t tQ5 P , FEE
17-4 COMMONWEALTH OF MASSACHUSETTS ----',,o 2-7
Board cfHealth, n MA..
DISPOSAL SYSTEM C INSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( Upgrade ( ) Abandon( ) an individual sewage disposal system
at
v
Disposal System Construction Permit No.
dated , 77
_ as described in the application for
Provided: Construction shall be completed within three years of the date of this p5 Ul local co}-ldi ' ns must be met.
1 ] l
Form 1255 Rev; 5/96 A.M. Sulkin Co. Charlestown, MA Date / Board of Health �' 1