HomeMy WebLinkAboutApp-Permit-ComplianceNo. YVioC-14a oz� FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �� , MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairyUpgrade( ) Abandon( ❑ Complete System ❑ Individual Components
Location 3,1 E el
Owner's Name BtA O na h) Mi-h ea
Map/Parcel# yq _ 3
Address 01 Loeb 8gf6 go., V'ij`
Lot# C! -f r—1
Telephone# 3Z 1 - 7 72, - %7 y U
Installer's NameDesigner's
Name
Address a
Address
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other F&tures
Design Flow (mina required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRZPTION OF REPAIRS OR ALTERATIONS Se -a ( Sed 7 C -A*n 1C
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t o place tem in eration u ertificate of Coliance has been issued by the Board of Health.
oe
Signed Date _1om 3
/V
0
Inspections
No.
Board of Health,
CERTIFICATE Of COMPLIANCE J& >P,G� R� 1, �C
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned eby certify that the Sewage Disposaa System; Constructed ( ), Repaired , U graded ( ), Abandoned (
by:%�
at % Z P C, r
has been installed in accordance with the provisions of 310 CMR 15.00 (Title ) and the approved design plans/as-built plans�relating to
application No. 6, dated AQ Approved Design Flow (gpd)
Installer a 0 Is M A tZ177 NC ,
Designer: - Inspector: de! - 4 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, L M OI. M MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
FEE ` ~. QV
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Permission is hereby granted to; Construct( ) I c ./0 s Repair(/ Upgrade( ) Abandon( ) an individual sewage disposal system
at z 2- 6 -0� c Z- le.&,( 1/"-j r(�- l /Z- as described in the application for
Disposal System Construction Permit No. , dated/ q
Provided: Construction shall be completed within three years of the date of this p IrriAt. All
local copoitions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 7tl Board of Health ��-`�