HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, l , MA.
APPLICATION FOR DISPOSAL SYSKM CONSTRUCTION
FEE
f--et'o / 2011.
TH DEPT.
Application for a Permit to Construct( ) Repair(vj Upgrade( ) Abandon( ) ❑ Complete System ❑ Individual Components
Location"56
�
Owner's Name `� '/S i fi r
Map/Parcel#(421
5,�ct 711Address
Lot#
Telephone# G7�'—
Installer's Name
Roker—x R ,(- Cb c�
Designer's Name ----
Addressbx
rJ el
gess —
Telephone#
0 - L e
Telephone# --
Type of Building
Dwelling No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( }
Showers( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �2 C6 �y 'DI,10:16U-72010 R O X
gpd
The undersigned agrees to install the above d ibed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pi a the syste peration until a Certificate of CompliancF has been issued by the Board of Health.
Signed e5 i Date
Inspections
No. 604W –1 FEE ` , 00
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth,x!111 I� ( , Am.
CERTIFICATE Of COMPLIANCE
E
Description of Work: ggndividual Component(s) ❑ Complete System !
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at
has been installed in acco dance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. --� dated 7Approved Design Flow '`.a'.. (gpd)
Installer r 162t;T?1Plk'C C. 01 l
Designer: "'"""' Inspector: Date:
—
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
13
No. 4604ADC --1-7 —33 Z'- �"� �j . �? t i �L FEE j ss. f_!�
COMMONWEALTH OF MASSACHUSETTS ck:r,#, 00-7 11-3
Board of Health, d' L Mj MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( --)"' Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No.' dated,
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit V1 local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health