HomeMy WebLinkAboutApp-Permit-ComplianceNo. Do tA-DC. 19 FEE $ � ��
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COMMONWEALT14 OF MASSACHUSETTS 0 D 4 0 Q
Boa'r'd of Health, _T bunt MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System O Individual Components
Location IqQ,
Long e lV iC
Owner's Name
Map/Parcel#
Address "-1z 4o n 1i4dV Or, V/1-0
Lot#
Telephone# 5 D C 3 e5 -- ` 91 o f
Installer's Name
f vailon
Designer's Name bq'1/ QS
Address /
�ed ��
Address S�1� lJ l/ut C h
Telephone#
elephone# J09 ,- ff3.3 —.2-1 7
Type of Building �� Heo 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
Plan: Date 41I0-1 5/J X Number of sheets Revision Date
Title
Description of Sbii(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
Theundersi a grees to install the above scribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further t o place t eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date - 2-7 -1
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No. > FEE :�a�..'+ 00
COMMONWEALTH Of MASSACHUSETTS �� 1 c..- i 9 tl
Board of Health, 7 -69M OlTAW , IVIA. %4e"
rMTHTCATME 0E Cf)M LTANCE
Description of Work:. ❑ Individual Component(s), ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ) Upgraded/ Abandoned
at
has been installed i 1 accQrd(ance with the provisions of 310 , MR 15.00 (Title 5) an the a proved design plans/as-built plans relating to
application.lo r-'ateds Approved Design Flow (gPd)
Installer
Designer: i� i`�� , <<;1 C i 1 + (� Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No., � � � �`..,. j � ,._ >C:�� � r C� � �f--- � C� t� V Y-�T` Q f `�.,! FEE
COMMONWEALTH Of MASSACHUSETTS � � r9r-(
Board of Health, YA12&6 t)n , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby,granted to Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at ti / -1 �l E �^r-�' , dated -; -1 as described in the application for
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Disposal :System Constructlion :Permit Na f
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Provided: Construction shall be completed within thrP ,Pa of the date of this perm' l local condition rust be met.
Form 1255 Rev. 5/96 A.M. Sglkin Co. Charlestown, MA Date
17-- 1 Board of Health
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