HomeMy WebLinkAboutApp-Permit-ComplianceNo.
l30WDC-V7-3eWCOMMONWEALT14 OF MASSACHUSETTS
Board of Health, J% MA.
v'4"ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT
Application for aPermit to Construct( ) Repair( ) Upgrade( -Abandon( ) - complete System ❑ Individual Components
Location 3
12 0anS
Owner's Name S u 1 vl
Map/Parcel#
i0 4,d
Address (l p c It 3
Lot#
CSL
Telephone#
Installer's Name
1:5 i � L %
Designer's Name IFS S (4 2
Address 3
yF�,y ��vl
Address r 0
Telephone#
S
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date C;2 — l --
Title Title
1-5
" Lot Size y,5 -0z:? sq. ft.
Garbage grinder WO
No. of persons Showers ( ), Cafeteria ( )
gpd Calculated design flow
Design flow provided
�ision Da�-G.
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned a es install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t t to ce sys n ra ' n until a Certificate of Compliance has been issued by the Board of Health.
Signed r Date ✓ /
Inspections
o.
r % ,
No. o 1AID C 1-7- ,j 8, 7C f P" � FEE �, 00
COMMON�LLT OF MASSA �T TT
Board of Health, yAe&6 uIV/7101
MA.
CERTIFICATE Of COMPLIANCE t�A /�!.c, /1 -7
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 4—T,—Abandoned ( )
by: C o r,,,4
r
has been installed in acco -dance vAth the provisio s of 310 CMR 15:80 (Title 5) and the a proved design plans/as-built plans relating to
n
application No. dated %' . Approved Design Flow* - (gpd)
Installerkr,p �`�
Designer: r Inspector: v6r Date:
'The issuance of this permit shalf fiot be construed as a guarantee at the system will function as designed.
No. &i ,9 DC_17 970 FEE , 00
Board of Health,V&QI U74: , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade,(, 4—A-5andon( ) an indi-ddual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. , dateed�d,,��
Provided: Construction shall be completed within a so ie date of this perp#. All local conditions must be met.
j� Form 12553 Rev. 5/9�6t A.M. Sultrin Co. Charlestown, MA � Date
�y 7 Board of Health
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