HomeMy WebLinkAboutApp-Permit-ComplianceNo, bb�'D�-e8'•(/?,� . FEE'_
d-f)MMONATTITH n1F MA-CCACITITIQUTTC
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Board of Health, `%ftpnO QTU AU
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application fora Permit to Construct( ) Repair (4pgrade ( ) Abandon( ) - ❑ Complete System WIndividual Components.
Location aC,tn
Owner's Name
y(�CMoFlh"�S�
Map/Parcel# w
Address
Lot#
Telephone#
Installer's Name s .
Designer's Name
Address `C sue.
Address -
Telephone#
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building —
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of.Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS r> 4 �X C n C.� QsAE l ,uys u n -
The undersigned agrees to install the above described Individual Sewage;' Disposal System in accordance with the provisions of TITLE 5-and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date , f l 1 j— : 3l—
Inspections
( !�( �T ��(r �(� (gym �/� � �T 00
COMMONWEAVE ll.gjtll 'U�1" .l�I�i SSACHUSETTS FEE 13�8
Board ofHealtla, _Yt�11. , MA.
CERTIFICATE Of COMPLIANCE� ),
Description of Work: W<dividual Component(s) ElComplete System
t The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired, Upgraded ( ),Abandoned
at L 'y�Cf P^ A,,kt... 12 rt
has been installed 'r acco da ce with the rovi tuns 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _&_, dated ��� l Approved Design Flow " (gpd)
Installer
Designer: Inspector: _ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
P_ `N V4,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ,YaR..A% f , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE �ll
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Permission is hereby granted to Construct( ) Repair(doT'—Upgrade( ) Abandon( ) an individual sewage disposal system
at r r �G.. �- . a 1�di l� " as described in the application for
Disposal System Construction Permit No. kf4/7, dated . f"
Provided: Construction shall be completed within three years of the date of this p/ert All local conditions must be;met.
�e) Farm 1255 Rev. 5/96 A,M,Sulkin Co: Charlestown, MA Date V �I d /'`�Board of Health f