HomeMy WebLinkAboutApp-Permit-ComplianceNo. a� C'-lb�—�6 �/��•� �" OV 10 ZR y' FE.E
r L/ COMMONWEALTH OF MASSACHUSETTS 0 f
Board of llealth, YA'@M1M+_A.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
tcpiation fora Permit to Construct( ) Repair( ) Upgrade(/ Abandon( - ❑ Complete System 24Individual Components
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Location L•{ 0 /L ,
Owner's Name
p/Parcel# $ g. i q 6
Address /1-
Lot# l q
Telephone#
Installer's Name ` `
Designer's, Name
Address a
Address '1114 .2,t
Telephone# 5
Telephone# 6000 1;-A
Type of Building
Dwelling - No. of Bedrooms 3
Other - Type of Building
Other Fixtures
Lot Size i b �b sq. ft.
Garbage grinder
No. of persons Showers( ), Cafeteria ( )
Design Flow (min. required) 1 l O gpd Calculated design flow.....43 D Design flow provided *3'61 - gpd
Plan: Date �J I �' N $ Number of sheets Revision Date
Title
Description of Soil (s) SOW-
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
to not to place the system in operation until a Certificate of i o pliance has been issued by the Board of Health.
\
Signed • I l_ _ Date
Inspections
�..2FEE
No. COMMONWEALT14®F MASS C S
Board of Health, `IA -2M OknA , MA•
f CERTIFICATE Of COMPLIANCE,
Description of Work:; & Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (L4, Abandoned (v
r.� r
by: 5
f
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at
has been installed in accordance with the pro ision of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. s' ~ dated '5 ��' .Approved Design Flow?, ! _(gpd)
Installer t L -O U :S ` —L4 IJ
,7,
Designer: � u c7,p --C Inspector: / f Date: ' . a -_
The issuance of this permit shall not be construed as a, guapfee that the system will function as designed.
d T
No. � C . W � 2 j� ? J 0 l.. c) o Eq -4 q t-,)1 FEE ' s: 0Z)
f j Y COMMONWEALT14 Of MASSAC14 TSETTS
Board of Health, AIA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted
(to; , Construct( ) Repair( ) Upgrade (V) Abandon (/) an individual, sewage disposal system
at Li U !' / (-` r� ' as described in. the application for
Disposal System Construction Permit No. �' _1 t dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. <F
Form 1255 Rev. 5/96 A.M.,Sulkin Co. Charlestown, MA Date l l� /� Board of Health I