HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE''
COMMONWEALTH Of MASSACHUSETTS
Board of H ,
ealth �� MA.
TION R DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora er it t Construct( Repair( ) Upgrade( ) Abandon( - ❑ Complete System O Individual Components
Location
/ '
Owner's Name,
Map/Parcel# ' Li;
Address
Lot#
Telephone#
Installer's Nam��60' 64�
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Designer's Name ✓i
Address
�iS .�c�f + +-
Address
ST
Telephone#
_ Z
Telephone# ze.�>F— 107,33 , Z-
Type of Building ,5. Lot Size sq. ft.
Dwelling - No. of Bedrooms 5 Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) S gpd Calculated design flow 31 --5 C Design flow provided gpd
Plan: Dater%/Z / ,7 Number of sheets Revision Date
Title
Description ofS'oil(s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSi ,l S f Al(, -1 j! .Afiy 7te 7� S J e&P7 e,
The undersi d eeece
the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further,agr to of to system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed Date � / /Z _
C 6` rrc-.4
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COMMONWEALT14 O�C,-MASSACH -MASSACHUSETTS
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Board of Health, _T�1 !I f 1 l , MA. ,� , y��✓
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) �Komplete System
The undersigned hereby certifythat the Sewage Disposal System; Constructed (.), Repaired ( ), Upgraded ( ), Abandoned O`
at
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /dated. Approx, `A Design Flow =T' (gpd)
��llr'v'7i✓J,4e
:Installer
Designer: dl/ / 4 /"S . �jj�#4:�/A) Inspector: ' Date: !j /
The issuance of this permit shall not be construed as a guard t Vdalthe system will function as designed.
No. ,-, 0FEET ...i it
Ar L
COMMONWEALTH Of MASSACHUSETTS
Board of Health, yr-iW/ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ---f Repair( ) Upgrade( ) Abandon( ) an indhiidual sewage disposal system
at w.r /��d� 1 ` t fdc as described in the application for
Disposal System Construction Permit No. v �! , dated
Provided: Construction shall be completed within three years of the date of this permit. Al ocal conditions must be met.
Form 1255 Rev. 5/96 A.M.SuullkinGo. Charlestown,MA Date. "�!� f 6' Board of Health
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