HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6 CA$-32-41 / r / b G / / FEE r�
COMMONWEALT14 Of MASSACHUSETTS
Board o Health, %�� iJ%�' , MA. '
APPLICATION FOP DISPOSAL[: SYSTEM CONSTRUCTION ERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade�bandon( ) - ❑ Complete System Individual Components
Location �, 7,
of err, 'd
Owner's Name
Map/Parcel#
/ Sj j
Address
Lot# L3
Telephone#
Installer's NameQ �
�
C Le "
�
�, Designer's Name
i
Address I /
rj
�m
Address -jam-7 ✓ /� /r'/ f `%� Y a
Telephone#
Telephone#
Type of Building ?
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Lot Size
sq. ft.
_ Garbage grinder( )
Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) gpd Calculated design/ flow Design flow provided gpd
Plait: Date Number of sheets J Revision Date
Title
Description of Soil (s) f2oe A 14,1
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS �yr rC/ / it�?o✓ �� /�
of Evaluation r` 1 7 - 19
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to gl a th teni in operation until a Certificate Compliance has been issued by the Board of Health.
Signed Date "
.
Inspections
No. COMMONWEALTH OF MASSACHUSETTS FEE � 0
( �tl Board of Health, , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System �% �C 411, ,✓ t
The undersigned hereb cer ' at the Sewage is osal S ste Constructed g y �h g p y Repaired ( ), U g adedandoned O
at
has been installed in accorda ce with the provisions o 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
✓
application No. � e- dated — .Approved Design Flow -�� f—(gpd)
Installer 1 1 _iel, �
Designer: Oak✓-$ �i�� ���� Inspector: Date: _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
,.. COMMONWEAIT9 OF MASSACIUSETTS
Board of Health, YAAMA(Mi MA.
DISPOSAL SYSTEM CONSTRUCTION `PKR 'IIT
Permission is hereby granted to; Construct( ): Repair ( ` Upgrade (V)""'Abandon { ) an individual sewage disposal system
at
Disposal System Construction Permit No. dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this p rm' .All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Charlestown, MA Date ' " Board of Health d m/