HomeMy WebLinkAboutApp-Permit-ComplianceNol)OVDC48-64(S
COMMONWEALTH OF MASS C14USETTS
Board of Ilealth, YW l i-� , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION
Application for a Permit to Construct( ) Repair{� Upgrade( ) Abandon( - ❑ Complete System 01
FEE 5510
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"DEC., Q 2018
Components
Ht:AITH DEPT_
LocationWo I
yl A t ArAAOwner's
Name
6
Map/Parcel#a
T1
Address
i -SJ}.
Lot#
Telephone#
Installer's NameLw
(Ami
Designer's Name
Address
OA �J
Address
Telephone#
-
Telephone#
Type of Building Lot Size sq. ft,
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers O, 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
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and
further agree to not to plait e s stem in oper tion until a Certificate of mp 'air a has been issued by the Board of Health.
Signed L Date
Inspections
No. C Ir� �t ^I^{ I� FEE
COMMONWEALTH OF MASSACHUSETTS C,
Board of Health, VA-(ziu.aOTIA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Upgraded ( ), Abandoned ( )
by: C A - > ZE r' rc' CA--hk (JT 0 C
at LP- l r fie' .i "1 i' � "-"�Vt- 7-
has been i stalled' accordance with the roviswm of 10 CMR 15.00 (Title 5) and the approved design plans/as.-built plans relating to
application No. ? -, dated !F '. Approved Design Flow �� (gpd)
Installer H E t_ c.4,
-.--� "" ' Ins Date: �� f
Designer: Inspector- P
The issuance of this permit; shall not be construed as a guar tee that the system will function as designed.
J
No. ' ` 0 (� °A '" � �,-� P �'�� ���- �_ � � 1 a FEE
� L .
COMMONWEALTH Off' MASSACHUS�ET S fLI
Board of Health, 42MOkM�,_--, MA.
DISPOSAL SYSTEM CONSTRUCTI®NT_ ERMIT
Permission is,herebygranted to; Construct( ) Repair`s' Upgrade
.1. _ n — j"
at
Disposal System Construction Permit No. 14--::2 f% ated -/_Z-
Abandon( ) an individual sewage disposal system
as described in. the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
4�
Form 1255 Rev. 5/96 A.M.;SulkinCo. Charlestown,MA Date„
~ 4 Board of Health r' rI ✓21-