HomeMy WebLinkAboutApp-Permit-ComplianceNo.wl)c-16-3 (e) 1 �� � r FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, j CL VK10 LA , MA.
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair(+,�Upgrade( ) Abandon( ) ❑ Complete System A6iidividual Components
Location SO < < CLrtY1 >
Owner's Name Gr� v
Map/Parcel# $ I ?
Address SQ.
Lot#
Telephone#V�i _
Installer's Name�1. C�ITA 4 Y i1 '�
Designer's Name
Address' , Z)ALXs� f A r6 Va ns M ��C 0 � qq
Address
Telephone# 5pg. �. g a(d
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Pian: Date
Title
Description of Sbil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
The undersigned agrees to* all t above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to ace system in operation until a Certificate of C plian a has been issued by the Board of Health.
Signed Date
Inspections
l
No. R 0 (4-bG1 Q ^3 ( 9 A4 FEE�• OO
COMMONWEALTH OF MASSACHUSETTS C" 1 &57
Board of Health, yQ t'YV1 o U , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 6/11dividuat Component(s) ❑ Complete System 4
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.Upgraded ( ), Abandoned ( )
by:a C C, -
at O
has been installed in accordance with the rovisron 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. — dated. Approved Design Flow (gpd)
Installer 180 `
Designer: AA Q,N Inspector: Date: (O
The issuance of this permit shall not be construed as a guaree that the system will function as designed.
4
No. FEE+
COMMONWEALTH OF MASSACHUSETTS �' r
Board (f Health, MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(, ) Upgrade( ) Abandon( ) an individual sewage disposal system
at .. _ as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within t�iree years` of the date of this permjt. All local conditions must be met.
Board of health
Form 1255' Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date