HomeMy WebLinkAboutApp-Permit-ComplianceNo." V
13) --1 F - 0 "y3 9 l-/
COMMONWEALTH OF MASSACHUSETTS
Beard of Health, �410 VTU MA.
FEE S3� 0
r. z?i%
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade(�AbandonO - omplete System D Individual Components
Location 6
il 4 IJ I t /t-1 LIZ
Owner's Name
Map/Parcel#
G-30,73. 1
Address 11-Jil 1__�Jl /(,P/�
Lot#
Telephone#
Installer's Name r, - l � A fw, j7-� CP ---d
Designer' Name S
Address
Jfh b- tj2R,
Address
Telephone#
C qL
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
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) See .Co s / a
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &Q -e- /04S ��
The undersigned est install the above describe.4 Individual Sewage Disposal System in accordance with the provisions -of TITLE 5 and
further agrees of to a r until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
inspections P
o-_`
COMMONWEALTH Of MASSACHUSETTS no
Board of Health, � qgffly O T4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) .a-omplete System.
The undersigned hereby certify that the Sewage Disposal *stem; Constructed O> Repaired ( )Upgraded ( ), Abandoned O'
bre: {; 1 1 1) wo)ti++_,� 6t, , jV
has been installe acc rdance with the provis ns of,,VO CMR 15.00 (Title 5) and p v design plans/as-built plans relating to
application No. "� dated r% Approved Design Flow/(d)
Installer - (F''. 11 r .,
Designer: li�SeEF -. IJ�SI i`J Inspector: s Date: _
The issuance of this permit shall not be construed as agu tee that the system will function as designed.
r
1 , - COMMONWEALTH I,TH OF MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
FEE' 7, ..3 > , (3o
= 2-20
Permission isherebygranted to; .Construct( ) Repair( ) Upgrade( ) Abandon( )an individual sewage disposal system
at �` as described in. the application for
Disposal System Construction Permit No. r'' /s , dated _� / — /f
L o ai -4,,. ,
Provided: Construction shall be completed within4lip@e,-s+eais of the date of this ixu it. All local coa-ditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Dated! ��P Board of Health
/LJ��+