HomeMy WebLinkAboutApp-Permit-ComplianceNo:;15OWN-0-33cO
I T-'fo
COMMONWEALTH Of MASSACHUSETTS
FEE_. W
C 0- 0�0
Board of Health, 99=1MO QVI , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair() Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location
r,(r
0
Owner's Name
S
l/ a✓�
Map/Parcel#
Address
��(/ ��
Lot#
Telephone#
?J
Installer's Name
o -e �,
�l
signer's Name
Address 1-7Ajet'-%
S S
Address
t
Telephone#
S_a e 7 7 (e
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
NM
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 5'&W -L- 47U AL
1 v s+ J n ( -e 7— D LL� -e r -
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Z- ' Z % J "�
i
Inspections
No. boo DC - h - 3311 -/ FEE* 0 5-115 �:-
COMMONWEALTH OF MASSACRUSETTS �Zko -rm37�/ �- _XG
TU Board of Health, 7Fi12—lYfb i J7 -N , MA. T k.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) El System AA � �� 04L "
The unde,�sgned hhe�'eby certify that th Sewage Dispos System; Cons cted ( ), Repaired W, Upgraded ( ),Abandoned
by: ..S uC' {t r 1 Gt v l% ea S �r'j f{ C cet P'C /// ...
at r W 6-r
has been installed in accordagcF with the provisio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating, o
application No. �.�"-+'� '� , dated .2 '" %� Approved Design Flow (gpd)
Installer
Designer: Inspector: L /' Date: _ —4!2�
The issuance of this permit shall not be construed as a guarana that the system will function as designed.
No.Ct►abC - i� "' A FEE
COMMON LT1I Of MASSACHUSETTS
/'7 a
Board of Health, YA&M O dr -4 oe
DISPOSAL SYSTEM CONSTRUCTION PERMIT
�\ Permission is hereby granted to; Construct( Repair Upgrade( ) Abandon(" ) an individual sewage disposal system '
at `( Ili as, described iii the applicatign for I
\,Disposal System Construction Permit 1`(0 --,dated -� t� / . a
Ppvided: Construction shall be completed within three years -of the date of this permit All local conditions must be met.
Form 12b5 Rev. 5/96 A.M. Sulkin Co. Charlestown, Mn Date ° - 4. of Health rS " ���✓