HomeMy WebLinkAboutApp-Permit-ComplianceNo. d Oc— `� 121
1-7— COMMONWEALTH OF MASSACHUSETTS
Board of Health, )(AKMOLMA , MA. 6
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
FEE
PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeAbandonO - ❑ Complete System •®individual Components
Location 2„ \ S t u
Owner's Name
VA-t—.Qkr
Map/Parcel#`
Address
(
Lot#
Telephone#
'S-OF5- Z' 76 �7
Installer's Name
Designer's Name
Address l bf k 1, d
Address
_
Telephone# 5b& CA- 06
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 9,tsw_- Garbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria (
Other Fixtures
Design Flow (min. required) 2� gpd Calculated, design flow ' Design flow provided d
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS _
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further ager -ewes two not to tem in operation until a Certificate of omplianc
ye has been issued by the Board of Health.
Signed V Date h —
No. VE
/ Board of Health. , MA. •I VZ
CERTIFICATE OF COMPLIANCE
Description of Work: U-BQividual Components) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded Abandoned ( }
by: Ct,1 �t` e
at -,-q
has been installed in acc``orda ce with the rovisions of 0 CMR 15.00 (Title 5) and th approved design„plans/as-built plans relating to
application No. `.1 dated �' Approved Design Flo pd) -'
Installer ; ^ i`t*�.. 1-A) 0f1- ,.moi -e� N 1 lr �c�
Designer: Inspector,; ) ate:
L3
The issuance of this permit shall not be construed as a guar te�in ee that the Yunction,esi eri'i
No. ��)C. -7”" � r (� '1 �l� IC:I�•` (2A )�� 14,
EEE
7,- COMMONWEALTH Of MASS ACHUSETTS
Board of Health, d d-1 , MA..
DISPOSAL SYSTEM CONSTRUCTIQN, PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( Abandon( ) an individual; sewage disposal system
atas described in. the application for
Disposal System Construction Permit No. %, dated
s
Provided: Construction shall be completed widlin three years of the date of this permit✓ ll local conditi59 must be met:
r
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA DateES" 8'-f Board Of Health
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