HomeMy WebLinkAboutApp-Permit-ComplianceNo. 601A DC --1 1-7241 BUS 1 F -i v —b-14
No.
COMMONWEALTH OF MASSACHUSETTS
Board of 11ealth, �i� _ MA.
FEE
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( .) Upgrade( Abandon( ) - Complete System 0 Individual Components
Location I(0
Wl,R35 %,� S AOC
Owner's Name
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Map/Parcel#
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Address0 a`" o v
Lot# Z,'? 9
Telephone#
Installer's Name
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` Designer's Name
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Address1e
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Address
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'telephone#
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Telephone#
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Type of Building ► n c t l
Dwelling- No. of Bedrooms 3 l
Other Type of Building
No. of persons
Lot Size Ski o `( sq. ft.
Garbage grinder
Showers ( ),'Cafeteria
Other Fixtures
Design Flow (min. required) 3 3 b gpd Calculated design flow 3 U Design flow provided 3 3 1 - gpd
Plan: Date Zo \ ol Number of sheets Revision Date
Title- 16 rnks�
Description of Soil(s)
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Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS hi - l U l V0 ✓ -r-kc I V -r
The undersigned agrees to install the above described Individual SewageDisposal 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.,
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Sighed LL� Date
Inspections
No.: C) (. i�" G.'L� FEE
COMMONWEALTH Of MASSACHUSETTS A'
Board of Health, _Y gV\k0ii_1: + MA. 0(C -
CERTIFICATE Of COMP.ICIANCE
Description of Work:. 0 Individual Component(s) Q- omplete System
The u,iAerst ned hereby certify that the Sewage Disposal System; Constructed >Repaired UPgradedAbandoned
at
has been installed in accordance with the -provisio s of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ;P - dated. d- Approved Design Flow �✓/ C pd)
Installer ! ' dt ::...i "tit 1 is C- iZ ( • , Cit C_
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Designer: i_ . f:. Vl v�svl i .� Inspector: — A o dzf��.�°'���1 Date:
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The issuance of this permit not be construed as a guarantee that the system will function as designed.
No. �
1 ;� i ? C �( ! �: 1 J < FEES"
COMMONWEALT14 Of MASSACHUSETTS 6
Board of Health, yM 1® SIM , MA.
DISPOSAL SYSTEM CONSTRUCTION HERMIT
Permission is.herebygranted to;, Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system
at"),mit r r k" as described in. the application for
Disposal' System Construction Permit No. %`1�" r , dated
Provided: Construction shall be completed within tiles oft e date of this permit. All local co� tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Cha lestown, MA Date i' ` Board Of Health
4