HomeMy WebLinkAboutApp-Permit-ComplianceNo. /�G FEE'���
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COMMONWEALTH Of MASSACHUSETTS
Board of health, ya & A , ALA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (/Upgrade( ) Abandon( O Complete System Vndividal Components
Location t 9
r, O,,Owner's N
Map/Parcel#
nname/n� 8,-&,
Address 1' o > Go)( `J� e..'6 i3
Lot#
Telephone# 7 r)o -DO'? • 5-033
Installer's Name �� �
Designer's `Name
��,. � sof ,�- jQ&aC Uh
Address qsl,,
Address
Telephone# 3pT_ /)
9 3919 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 providedgpd
Number of sheets Revision Date
Name of.Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS aeu1 ��� S(7'IY,OUS (lYl 136X 0n /u
The undersigned agrees to' all th ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not 1 system in operation until a Certificate of C mpliance has been issued by the Board of Health.
Signed Date
Inspections
No. /5-d J' % / fit � 1 FEh
t1
COMMONWEALT14 Of MASSACHUSETTS
CHUSETTS J
Boardof Halth, ' Y'_" MA
CERTIFICATE OF COMPLIANCE
Description of Work: 1Individual Component(s) ❑ Complete System ✓ ` .a�(�
.J
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (k, Upgraded ( ), Abandoned ( )
by:y"
l
t�^
at.,
has been installed in ccordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.I�� `Z / datedY - !8 Approved Design Flow (gpd)
Installer l.i V-'- 1 't
Designer:3� r- l; t. Inspector t J ' 4 Date:
i
The issuance of this permit shall not be construed as a guarantee that the,system:will function as designed.'
No.0= �_ i `ice 9
�il�l`'� � FEE
16 - COMMONWEALTH Of MASSACHUSETTS
Board of Health, %- t^, x.1. ` MA.
DISPOSAL. SYSTEM CONSTRUCTION PERMIT 14V
Permission is hereby granted to; Construct( ) Repair(;,X) Upgrade( ) Abandon( ) an individual sewage disposal system
at �r f .~
'�� � fir'+ f�' � � V) 1) �l �a> f' .�'� ! � .` � � ' ; ' ?-�� , :'� �, as described in theapplication. for
Disposal System Construction Permit No. dated �` '7
Provided: Construction shall be completed withneas tit'ie-Aate of this permit.
_V1 local conditions must be met.
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Form 1255 Rev. 5/96 A.M.SulkinCo. Charlestown,MA Date r,,1�6oard of Health