HomeMy WebLinkAboutApp-Permit-ComplianceNo. FfojFDC-1 `-0ZP0 FEEiOD
COMMONWEALTH Of MASSACHUSETTS C4171
Board of Health, yj0 UTW , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) :Repair(V/Upgrade( ) Abandon(} ❑ Complete System O Individual Components
Location
)9ruc- e -�5
Owner's Name Ile
Map/Parcel#
1 3
Address
Lot#
Telephone# `O
Installer's Name 0 1)h/ G
Designer's Name
Address
( of
Address
Telephone#�,�
(iQ Z
Telephonefrir
Type of Building Rr S (t".r I i or L Lot Size sq. ft.
Dwelling - No. of Bedours Garbage grinder {
Other -Type of Buildi No. of persons Showers ( ),'Cafeteria
Other Fixtures
Design. F (min. req ed) gpdj culate esIgn flow Design flow provided gpd
Plan; Date um of she Revision Date
Title
Description of S"oil(s IV
Soil Evaluator Form No. Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERAT 4 t e—
'B M c fe IPl f e 17 ed- � ,� 0 � -P pp-, �' L ✓rte -� U �/1 %mo i- !� _ �� i C 7LL ✓�I�
The undersi ed agrees to ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further s t n to ce th system in operation until a Certificate of Compl'ance has been issued by the Board of Health.
Signed Date Z
Inspections
No. F7t��YG�I%"V� FEE _. 6•M
7,
COMMONWEALTH OF MASSACHUSETTS 129
Board of Health, AbgM p y 4 , MA.
CERTIFICATE Of COMPLIANCE
Description of Work:. 'Individual Component(s) ❑ Complete System
The' undersigned hereby certiiff that the Sewage Disposal ys m; Constructed ( ), Repaired Upgraded( ), Abandoned ( )
at '51
has been installed in acc rd• nce with the -ovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 12 dated. `� F—�-7— Approved Design Flow (gpd)
Installer Pe l s7- (2*L i 674-0 1
Designer: Inspector: _ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �Q i7 �%' G`:G��C)�( FEE
Board �f Health,
DISPOSAL SYSTEM CONSTRUCTION ERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at ez ✓C"r 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 condlitions. must be met..
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ! �! r� Board of Health `S
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