HomeMy WebLinkAboutApp-Permit-ComplianceNo. � otnc,1 ` —11(b5 ,��5
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/ 7- COMMONWEALTH OF MASSACHUSETTS
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3327
Board of Health, `[-171 MA.
APPLICATION FOR DIS 10SAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) El Complete System klindividual Components
Location
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Owner's Name 1,t4ck P044ecS
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name
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Designer's Name
Address . �� BOX
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Address
Telephone# Yen z4y
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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 Design flow provided . gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION O PAIRS OR ALTERATIONS p (6c� "UX �e. eOtiel'
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The undersi d ee to inst a above d ual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agr of a cyst on until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. C^'� ( �"-./C �".�df /' FEE _
— � COMMONWEALTH OF MASSACHUSETTS
Board of Health, yagmbtm, MA.
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CERTIFICATE Of COMPLIANCE-
Description
OMPLIANCEDescription of Work: ®"Individual Component(s) ❑ Complete System f i
The undersigned hereb(r certify that the Sewage Disposal System; Constructed O, Repaired (Upgraded ( ), Abandoned ( )`
by: C v A: Ccs,
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has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated. / �'% Approved Design Flow (gpd)
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Installer �G t C(-- ! l -- 4 o a -e- /1 (�
Designer: Inspector:
Date: />_=
The issuance of this permit shall not be construed as a,gua ee that the system will function as designed.
No.IipC.-'I 744(i 5— C �'7+Y CUi� SFS r'C. 1 P-4 FEE
`� -2 - COMMONWEALTH Of MASSACHUSETTS ��-� 32 7
Board of Healtic, ��o t1T , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to Construct( ) Repair(V) Upgrade( ) Abandon( ) an indiv=idual sewage disposal system
as described in the application for
Disposal System Construction Permit No. - , dated,(
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M.;Sulkin Co. Chalestown, MA Date oard of Health
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