HomeMy WebLinkAboutApp-Permit-ComplianceNo. a r a
FEE s'
COMMONWEALTH Of MASSACHUSETTS
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Board of Health, A'CUTH HEALTH , �PT. .
s
APPLICATION FOR DISPOSAL SYST ` ONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location .
Owner's Name , -,5r,,,,- p
Map/Parcel# ��
Address
Lot#
Telephone#
Installer's Name �
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building --,el ��/P '�.��%Tv lf�r. �� �i <,/ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons7� - Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
gpd Calculated design flow
Number of sheets
Design flow provided
Revision Date
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESSCRIPTION OF REPAIRS ORALTEERATIONS �p/v,r,-- Ferri i��5•'cy.� /✓?oX
The undegned agrees
further es to not to/
gpd
the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date I I / `i G
C®MMON ILT14®F MASSACHUSETTS. No. 61 � r
Board of Health, ✓k o ✓*�'
CERTIFICATE Of COMPLIANCE / &y
Description of Work: Id Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( )> Abandoned ( )
by:
at ,9 �i��.� :� /�. S ��G-�. e.� �h -�f� �a6'B S•l
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. QD, dated . Approved Design Flow (gpd)
Installer _
Designer: ^---__ Inspector: �%u� Date:
The issuance of this permit shall not be construed as a gua we at the system will function as designed.
No. FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, /Yl/ .,y
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(- Upgrade ( ) Abandon( ) an individual sewage disposal system
at -/ /l/ �h� ��1 �`!�c /�/? as described in the application for
_ J
Disposal System Construction Permit No. , dated ^4✓1
Provided: Construction shall be completed withka-:ki*@�s of "the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health
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