HomeMy WebLinkAboutApp-Permit-ComplianceNo. 4300 UK-- 1'zA 1'7 /—/,0 130ev FEE
COMMONWEALTH OF MASSACHUSETTS &4p -m
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for Permit to Construct( ) RepaitV Upgrade( ) Abandon( ) ❑ Complete System ndividual Components
Location 4NQ
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C l{ Owner's Name <r Z}
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name �Ld
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Designer's Name
Address �`-1 d
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Address
Telephone#
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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
DESCRIPTION OF REPAIRS OR ALTERATIONS Qk � U LA-- GC- (ZP �.e � L S . ��G G �c
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.��..�_ _ DateI �
Inspections
No.`a t i sr ,' -. (Cf"' 2 Oct FEE 1
COMMONWEALTH OF MASSACHUSETTS d)t�k 1 -77 7
Board of Health, )69V=ffi Nn , MA.
CERTIFICATE Of COMPLIANCE �
Description of Work: 0 ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (0/'Upgraded { j, Abanoned
by:
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has been installed in a&'d', a S with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.. ^ �" yt'� ,° , dated 2 6- fy : Approved Design Flow "� (gpd)
Installer
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Designee: Inspector: �::- � � �, ,..-�:�....�� Date:
The issuance of this permit shall not be construed as a, guarantee that the system will function as designed.
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1 COMMONWEALTH EALTH Ot" MASSA`L.HUI ETES
Board of Health, YV, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to,; Construct( ) Repair( t" Upgrade( ) Abandon( ) an individual, sewage disposal system
at �= r �'=A '�� ' ii r. r utJ� A uo ,,� `-A as described in. the application for
Disposal System Construction PeAu Nodated
Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date «aL Board of Health