HomeMy WebLinkAboutApp-Permit-ComplianceNo. Nr,c-lB-'iib
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, 4A -M DUrr1i , MA.
FEE 4 5 5't' ft
APPLICATION FOR DISP®SALSAY TEfi�'1[ ��� TI�IJCTI�� PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade AbandonO - Complete System L3 Individual Components
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Location ` C
Owner's Name
Map/Parcel#S 1
Address + L
Lot#
Telephone# cS C8- .3 cp S3&off
Installer's Name I L l.� ()9)14 Id �� '1--
Designer's Name 85C (;,�,O
Address Q3
Address 3 4 IF
Telephone#
Telephone#
Type of Building 0 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
Plait: Date Number of sheets Revision Date
Title
Description ofSbil(s) S -" Q0,) i O
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 3`ef Sw, ,-L PS r
The undersigned agr tg tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to the t until a Certificate of Compliance has been issued by the Board of Health.
Signed Date _3 -y z 3 .,x/00 F
Inspections t
FEE °' . C0
COMMONWEALTII OF MASSACIIUSETTS
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) CLC,omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded abandoned ( )
C
at i I ! f" I rl n t Wit+ �G;iY t°V1r,,has been installed iR accordance th the provisions of 3 CMR 15.00 (Title 5) and t e pproved design plans/as-built plans relating to
application No. - dated a Approved Design Flow (gpd)
Installer l-: f % k, a 03 e�'r 1% r,S 1 1
Designer: 0} C 6rn;.g g
_Inspector:f w' a Date: !(n x
The issuance of this permit shall not be construed as a guarant a that the system will function as designed.
No. `f ' )C 'i.; f4J:: t.l l�� Vi`i-+� i�%� FEEcx-)
COMMONWEALTH OF MASSACHUSETTS
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Board of Health, � L f7 (rM MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade(,jAbandon( ) an individual sewage disposal system
at i i -• t C i�,.� ra t eN� , �t t /11,4 as described in the application for
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Disposal System Construction Permit No, /. dated 6 �
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Provided: Construction shall be completed within three years of the date of this permik.�l ocal conditi�p�qs must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 7t-- Board of Health