HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTH Of MASSAC14USETTS
Board of Health, ��i�r°��1 MA.
APPLICATION FOR DIS
" plication for a Permit to Construct( ) Repair( ) U
FEE W ��
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®� � TEM CONSTRUCTION PERMIT
pgrade )Abandon ( ) Complete System 0 Individual Components
ocation j
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Owner's Name (� , r i� A \ 6
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Address )�'�_c3a.Map/Parcel#
Lot# r(
Telephone# os ..- "3(�, ry
Installer's Name
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Designers Name � , �
AddressP. C?
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Address ?0_g0
Telephone#-
Telephone# ,
Type of Building
Dwelling - No. of Bedrooms
Other Type of Building _
Lot Size L sq. ft.
Garbage grinder( )
No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min?>3o. required) �o gpd Calculated design flow CJ
Plan: Date 1) x%11 Number of sheets 07
Title
Description of Soils) t
Soil Evaluator Form No.
Design flow provided :15:5 % gpd
Revision Date
Name of Soil Evaluator A11r�1 Vc- Al }" OPIf—Date of Evaluation
A to
DESCRIPTION OF REPAIRS OR ALTERATIONS I >J S 1 r l l1, j O(J�i �- 11.0 — �JC� ✓`
The undersigned agrees to ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to a the a operation until a Certificate of Compliance has been issued by the Board of Health.
Signed G Date d % 2
oc
Inspections
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No. ON�` ~%`✓ f "g" f\t°�`%FEE
COMMONWEALTH Ods MASSACHUSETTS
Board of Health, 7 A mb am , MA.
CERTIFICATE TE Of COMPLIANCE
Description of Work: 0 Individual Components) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(bandoned ( )
by:
at --It =ER ®1-�
has been installed in accordance with the provisi ns of 310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)-
Installer L 1 }
Designer: t - �s611 Inspector: Date:
The issuance of this permit shall not be construed as a gua4Wt6e that the system will function as designed.
No. V,0 C-1 % 3_5 9 55��c rYG.. Co
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0 COMMONWEALTH OF MASSACHUSETTS
Board (f Health, 1 k MA.
DISPOSAS. SYSTEM CONSTRUCTION PERMIT
FEE �3 515', 0()
Permission is hereby granted to; Construct( ) Repair( ) Upgraded Abandon( ) an individual sewage disposal system
at 1 �'t t _g . r C' -r' as described in the application for
Disposal System Construction Permit No. 'r/ 1rJr, dated .
Provided: 'Construction shall be completed withi oio� h d to of this permil2 Al cal conditio ,s-riiust be met.
Board of Health
Form 1255.. Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date . '� �� ,