HomeMy WebLinkAboutApp-Permit-Compliancei
COMMONWEALTH OF MASSACHUSETTS
Board ofllealth, yyp , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ,) Upgrade( bandori( ) - 4a' omplete System O Individual Components
Location
C O �,,.g �' la,.
Owner's Name Tyr G41 in F0 r 13 .of
Map/Parcel#
7"�
Address
Lot#
Telephone# 0 F co % 1/.
Installer's Name
l2 I h,� oro a .�,-d Ccl ns'�
Designer's Name P L4 h le- 0,r
Address a 3
-
ffn L'4_J '� G7
Address c�Y
Telephone#
S
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building —
Lot Size _ sq. ft.
Garbage grinder ( )
Showers( ), Cafeteria
Other Fixtures
Design Flow (min. required) I la X3 = 3.An gpd Calculated design flow Design flow provided gpd
Plan: Date d-1 ` 1 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agramae,-+
tthe above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notsyste m o ati a Certificate of Compliance has been ued by the Board of Health..
Signed Date
Inspections
No. I P- "`2�75 FEE 0Q
/fir C®�'1[MONW LTH OF SSACHUSETTS c - 19 ce I
�� Board of Health, OUTR
CERTIFICATE OF COMPLIANCE
Description of Work; ❑ Individual Component(s) mplete System.
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( )Upgraded (Abandoned O'
by: (;rd I , S Ai rt t Cc,,„ �,i'
at Is C c C G (4,7e i I P (. ue S<i
has been installed i accordance with th rovis'ons o�10 CMR 15,0 (Title 5) and the approved design plans/as-built plans relating to
application No. dated " Approved Designn Flow !� � (gpd)
Installer / f i iA-& 1 r4' / J
Designer: r of 1 iL- )tat , 0tlo+� y d' f �' Inspector- _Date;
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. i "e <7 FEE
CO MONWEALT14 Of MASSACHUSETTS
Board of Health, YUNWME, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Perrhassi6i is hereby granted to,; Construct( ) Repair( ) Upgrade(—)--A"bandon( ) aninditndualsewagedisposal system
at� Lt/--p 1 j fY+'r, ! %''t7 as described in the application for
Disposal System Construction Permit No. `r'�� , dated .
Provided: Construction shall be completed within airC4of this perm' All local con 'tio must be met:.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date S ff Board of Health �' '�