HomeMy WebLinkAboutApp-Permit-ComplianceNo. le7ow'D c-1-7-3322 b
17 - 4-7 COMMONWEALTH 01F MASSAC14USETTS
Board of Health, 1 ���, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
Application for Permit to Construct( ) Repair( Upgrade( ) Abandon( ❑ Complete System ❑ j,
FEE %P,30t VV
c 00-2915
RECEIVED
FEB 172,017
HEALTH DEPT.
Location C>U �`
Owner's Name J�
Map/Parcel#
Address T1 C
Lot#
Telephone# o — V -- lo�
Installer's Name ��b.e �� ��
Designer's Name _---
Address
ddress
Telephone# _ js,
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
gpd Calculated design flow
Number of sheets
Lot Size sq. ft.
Garbage grinder( )
_ No. of persons Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator i -'l Q
Date of Evaluation
Q•� k
DESCRIPTION OF REPAIRS OR ALTERATIONS ���� U IV0 tj o X
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 pla e e in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed gb i Date ! /
Inspections
FEE 55� 00
1
Beard of Health, � l� , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Com onent s ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: PIC, 6e r R vri h J
at `" W c
has been installed in accor ance with the provisi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated f 7 Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. i 4 t�-7
4-7 COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(v/ Upgrade( ) Abandon( ) an individual sewage disposal system
at V�o l , S` 9! l%%` 1 as described in the application for
Disposal System Construction Permit No./_, dated ° f
Provided: Construction shall be completed within three years of the date of this permit. All local condition . must be met.
Form 1255 Rev: 5/96 A.M. Sulkin Co. Charlestown, MA Date "( P Board of Health / V
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