HomeMy WebLinkAboutApp-Permit-ComplianceIWVn`-M"C- x$_630L, FEE/O-100
COMMONWEALTH a MSS SETT c43�
Board of Health, Y®4,�'I� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Constructgr epair( ') Upgrade( ) Abandon( ) - 3 -Complete System 0 Individual Components
Location C
Owner's Name ,
Map/Parcel#_ 1
Address �-- r `
L
Lot#
Telephone# rJ s.
Installer's Name C, !S _
Designer's Name 54Q AM) C44Q t • # ,
144
AddressAddressAl
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14 ec.
Telephone# k4ol,
Telephone# =,^
Type of Building �_S jcl{�_�C�, __ Lot Size y&_9 sq. ft.
Dwelling - No. of Bedrooms 611b Garbage grinder A) o
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min, required) gpd Calculated design flow �YVO Design flow provided Y4" gpd
Plan: Date a_ Number of sheets Revision Date
Title
Description of Soil (s) `jW,!K_ ,- = L� Epi 6► s YE =-Zj�z 'C /t oZ n-6 04 G 05A 3 � ��/3� p1�"
Soil Evaluator Form No. Name of Soil Evaluator 1E7L4Wt Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 theto in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. -�""L-P ��FEE
�I. Q
COMMONWEALTH OF MASSACHUSETTS kl 3-71
Board of Health, `_/h91' z) u1n4 , MA. 04
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) A'1 ompiete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired { ), Upgraded ( )> Abandoned ( )
at
has been installed in accordance with the provisions of 310 -CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated 1 `4-pproved Design Flow K -x (gpd)
Installer
J,
Designer: ,a .. (`Inspector: Date:
The issuance of this permit,shall rot be conktalued as a guar a that the system will function as designed.
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No. i�FeJl� t�� �`V�'?i �� 4^^` FEE f.ls': 0'1
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y A 1,M4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to 'ConstructiX Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at �.$�� D? t �) as described in the application for,
Disposal System Construction Permit No. s� cr, dated
C�` `
Provided: Construction shall be completed within tL s"of"f�ie date of this permit. Ql1ocal corWitions must be met./
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Form 1255 Rev. 5/96 A,M,Sulkin Co. Charlestown, MA Date't � I�Board of Health
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