HomeMy WebLinkAboutApp-Permit-Compliancet No. "s—z"
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COMMONWEALT11 OF MASSACHUSETTS TS
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Board of Health, &O' Oar14 me AIM -{ 9 N18
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P I RNikT` , :Ery T.
Application fora Permit to Construct( ) Repair( ) Upgrade( bandon( omplete System U Individual Components
Location
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Owner's Name &1'14')
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name
Designer's Name��
Address
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Address 0 O� 4/8r j
Telephone# C%
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Telephone# U ,_.�
Type of Building /LS! *&i) el- , - Lot Size sq. ft.
Dwelling -No. of Bedrooms i2qm Garbage grinder ( )
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow ,mein. required) gpd Calculated design flow ZZd Design flow provided C gpd
Plan: Date ? �� i 06 P Number of sheets Revision Date dAe, 7, !24r9
Title
Description of Sbil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 5 S76_A7
The undersigned a est rust the above described Individual' Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre o t to lace a system in operation until a Certificate of nin 'auce has been issued by the Board of Health.
Signed Date
Inspections
No. .U1 NAT) .,...(S"2-91-7 FEE
COMMONWEALTH Of MASSACHUSETTS t = � �•�
Board of Health, Y ! b in , MA. �V_ r
!CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 2r!6 omplete System p�
The undersi ned kiereby certify t the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade W, Abandoned
by: i D? A)r tle G C
atMOW
has been installedt in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. f ' 6/ 1, , dated / Approved Design Flow ' ' (gpd)
Installer _ C OaTT—
Designer:j Qc'0-1(L_1'Q Inspector:-'�'�"" Date:
The issuance of this permit shall not be construed as a guarantee th t the system will function as designed.
/ COMMONWEALTH Of MASSACHUSETTS
Board of Health, �,l � i n QMA , Am.
DISP®SAS. SYSTEM CONSTRUCTI®N PERMIT
FEE _' i, 0LJ
UL4I -7
Permission is hereby granted to; nstruct( ) Repair( ) Upgrade (b,e) Abandon ( ) an individual sewage disposal system
at �> 11,�;?t� C , r as described in. the application for
Disposal System Construction Permit No. 106, dated
Provided: Construction shall be completed withino')the date of this permit All local conditions must be meet.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date - / i Board of Health