HomeMy WebLinkAboutApp-Permit-ComplianceNo.� � �� x FEE
1COMMONWEALTH OF -MASSACHUSETTS
Board of Health,
APPLICATION FOR DISPOSAL SYSTEM ST CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(/j Upgrade( ) Abandon( ) - ❑ Complete System ''Individual Components
Location
Owner's Name ,v1P�r�e
Map/Parte
Address
Lot#
,
Telephone#
Installer's Namec-
Designer's Name
Address (
f
iS Address
Telephone#
ug
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other- Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 92.�`C �� ��j�C��Ci► Q t 5� by �C��
gpd
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 place the system in operation until a Certificates of Compliance has been issued by the Board of Health.
Signed Dake
Inspections
No. M uD C-1 ? 0 1 6 -7 FEE
COMMONWEALTH OF MASSACHUSETTS
7—TI 7 Board of Health, T' b �� , ,2VIA.
CERTIFICATE Of COMPLIANCE
Description of Work;. E,.YIndividual Components) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded O, Abandoned ( )
by: ZX e�,NA
at
has been installed in accordance with the proylisigns of 310 CMR 15.00 (Title 5) and tproved design plans/as-built plans relating to
application. No. 7, dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date: "'"�4 f % - -
The 'issuance of this permit shall not be construed as a guarana that the system will function as designed.
p� —7 c
No. �•�. � � 'Q � � / J C C�- M . FiZk N (c" FEE
C&MONWEALTH OF MASSAC14USETTS
/7,2/7
Board (f Health, i4 i Q li- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to,; Construct( ) Repair(✓ Upgrade( ) Abandon(—)'an individual sewage disposal system
at !� ��e`ti P .�" \,ra ja,Q `,J-eC� f Pw..�.J as described in the application for
Disposal System Construction Permit No. % j / �? dated P r •�
Provided: Construction shall be completed within three years of the date of this permit? local cond' ' s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date S A / 7oard of Health