HomeMy WebLinkAboutApp-Permit-ComplianceT No.' go4tV) c—t -�-b3 BG' 4>11-,e e � z5,x FEE
COMMONWEALT14 Of MASSAC14USETTS
Board of Health, / 4--MOV-1—A „ MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) RepairO Upgrade( ) Abandon( ) - ❑ Complete System 34hdividual Components
Location - �`�C "^Ov
Owncr's Name F—k\z
Map/Parcel# Z3,
Address �rNloltiD l}.
Lot#
Telephone#
Installer's Name ��� M ^
Designer's Name
Address
Address
Telephone# Sb a ei m nom
Telephone#
Type of Building Lot Size .: sq. ft.
Dwelling - No. of Bedrooms Garbage grinder {
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (min. required) V gpd Calculated design flow Design flow provided I 4�; gpd
Plan; Date Number of sheets Revision Date
Title
Description of Sbil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 ' peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �O k j 1 k 1
Inspections
No. lE-1 VC'�� `'a?t �l EF 06
COMMONWEALTH OF MASSACHUSETTS�
44
Board of Health, A tZM 0 U N , MA. i
CERTIFICATE OF COMPLIANCE Y u
Description of Work: 1"dividual Component(s) ❑ Complete System %(
The undersi ned hereby certify that the Sewage Disposal System; Constructed (}, Repaired��, upgraded (: ), Abandoned ( )
by:
at 44r. 9t r s
has been installed in actor ante with the provision of 31 MR 15.00 (Title 5) and the a roved design plans/as-built plans re"latito
application No. / 7—, -"',too dated. /61 - 7 ,'f. (Approved Design Flow 414� (gpd)
Installer
6C�
Designer: --- Inspector: , Date: /0 _;` r
The issuance of this permit shall not be construed as a guaree that the system will function as designed.
No. V��))�� i l � n y -
20 1 Q, ' I o C. 0-n (� t"?�A f 1--- FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, VAamoov_, MA. .
DISPOSAL. SYSTEM CONSTRUCTIONT PERMIT
Permission is hereby granted to;, Construct( ) Repair �Upgrade ( ) Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No
dated
as described in the application for
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. Charlestown, MA Date 111d Board of Health ✓