HomeMy WebLinkAboutApp-Permit-ComplianceNo. 980CA%48x5 Mec�/ 1.[� FEE' yO�
COMMONWEALTH Of MASSACHUSETTS jr,*11qA(,0,6
Board of Health, �� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair ' Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location I Ra/7
^�Q
Owner's Name
Map/Parcel# J 6,�
/' �,%,� 17
Address 16
Lot#
Telephone# 5-0, `330 ' 5-E I
Installer's Name
L` �_
Designer's Name
Address 4/6 et' Z6 7
Address
Telephone# ! 7Fo�6�
J��a
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 S'oil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS/OR ALTERATIONS N PL (::, C
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n o the tem in operation-until'a'Certficate of Compliance has been issued by the Board of Health.
Signed Datef� `E% f 7
Inspections
No. lio 14 I� r'- E -1 6 Q �,5 FEE � r , �� a�.)�%
J1 COMMONV Y ]C I IJHI[7t OF MASSACHUSETTS i
Board of Health, ri MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 2 Individual Component(s) ❑ Complete System a -
The undersigned hereby certify that the Sewage Disposal System; Constructed (-I, Repaired ( ), Upgraded ( ), Abandoned ( )
by:- .e uJ p N T) L�? E.:4,3,j i Q16 L„
at % : n2 it of
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)
Installer `�� ✓
Designer: _._ Inspector:�.�/� r Dater
The issuance of this permit shall not be .construed as a guarantee that the system will function as designed.
No. i {E. �� - i �= 1 V��i 1ti.) J )f. -i i{�C_1��9�- FEE
-�_ COMMONWEALTH Of MASSACHUSETTS� �� . ? i a j6s
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is herebygranted to; Construct( ) Repair( -Upgrade( ) Abandon( ) an individual sewage disposal system
at Gra � 9 � 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 � permiL All local conditions must be ;met.. r
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health .r