HomeMy WebLinkAboutApp-Permit-ComplianceNo. /�///��L la n � t! i` /��• FEE' D CID
COMMONWEALTH LTH OF MASSACHUSETTS
Board of Health, YAMoo-al mi.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) 0 Complete System dividual Components
Location , h v` ,,-
Owner's Name
Map/Parcel#
Address J r
Lot#
Telephone#,y ro 9 Lj 6 6,S SO4 ,6-3 7 >' �
Installer's Name r ` 1 j V j -j4T3 CC -A, 01-
Designer's Name
Address 1 12
Address
Telephone# Gq-
Telephone#
Type of Building 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 Number of sheets Revision Date
Title
Description of Soil,(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPT O F'
L
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The undersigned ees to install the above desc 'bed Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees n to a the tem i u Certifica Compliance has been issued by the Board of Health..
Signed Date O
No. �.. %i0 FEE ?
16 - �>-3 �- COMMONWEAI.T14 OF MASSACHUSETTS
Board ofHealth, 1 4 , MA. 4,
CERTIFICATE Of COMPLIANCE
��
Description of Work:•"O Individual Component(s) El Complete System.��--
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ); Upgraded,(- -,-Abandoned ( )'
at S-Ct4l ! e--t%�
4b 4-
has beat on Noled in acco�da ce with the p 4 is >ns of 31 -�MR 1 . 0 (Title 5) and e approved design plans/as-built plans relating to
pp '. dated �,_ p -p—,rived Design Flow - - (gpd)
Installer i' i I, S S l''+� 1/ r
Date: /l
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Designer: Inspector: 10-AA . ,2 ✓_
The issuance of this permit shall not be construed as a, guarantee that the system will function as designed. ,
FEE
r COMMONWEALTH Of MA5SACHUSF'TTS
Board of Health, -0 MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( Repair( .) Upgrade ( ) Abandon ( ) an individual; sewage disposal system
at J j -C,� r� r d-a. �;;, T ry 1. 17 01 56s described in the application for
Disposal System Construction Permit No. dated �d
s
Provided: Construction shall be completed within three years of the date of this permit. Al local conditions mist be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA D'ate9- -) j 4 Board of Health / l '