HomeMy WebLinkAboutApp-Permit-ComplianceNo. `� aL��L! �li�J�i"[�J �Y �� FEE065y
-vc-�a-Er��lg
COMMONWEALTH .T OF MASSACHUSETTS � y
Board of Health, � ,NIA.
C
APPLICATION.FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )(epair( ) Upgrade( ) Abandon( ) - plete System O Individual Components
Location
Owner's Name
�� Lj
Map/Parcel# 71
_.
Address
L
�
Lot# s
Telephone# E
y7
Installer's Name
-2G
Designer's Name
Address 179
Address
3
� " � c �
Telephone# jro f % q - 6
Telephone# b
Type of Building L� E`t�flE� J10� Lot Size_ ,. sq. ft.
Dwelling - No. of Bedrooms /P�, Garbage grinder ( )
Other - Type of .Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures 7
Design Flow (min. required) /7
Plan:' Date 1 C L'
Title
gpd Calculated design flow Design flow provided gPd
Number of sheets _ ) Revision Date
Description ofSoil(s) J 9eiG _ l- ( s y" /mem
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF`REPRS OR ALTERATIONS I'ins/
Date of Evaluation
The undersigned agrees to install the above described Individual Se,wage.Disposal System in accordance with the provisions. of TITLE 5 and;
further agrees to not to place the system in operation until a Certificate of C mplianc has been issued by the Board of Health.
Signed Date t
3 Inspections
(�a+`0
15
Board of HeaFEE � 5 3 . (A
COMMONWEALTH OF MASSACHUSETTS
lth, , MA. om,+
CERTIFICATE QF COMPLIANCE 1 � \`
Description. of Work: ❑ Individual Component(s). 1nplete System
The undersigned hereby certify that the Sewage Disposal System; Constricted ( )., Repaired ( ), Upgraded /Abandoned ( )
at
9L 1 1 44044z;
has been installed ina ccort with the provisions of 3 0 CMR 15.00 (Title 5) and the:approved; design plans/as built plans relating to
application No. /` dated . Approved Design Flow _(gPd)
Installer ed
Designer: ffec 5 , inspector: A :OF�� Date:
The issuance of this permit shall not be construed as a guarantee th the system will function as designed.
4
��` t� r
FEE 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y11�09ti~ , MA.
i DISPOSAL SYSTEM[ CONSTRUC ION PERMIT
Permission is herebygranted to;; Construct( ) Repairs -{Upgrade Abandon(` ) an individual sewage disposal. system
t f//
at a41
b \I L4"Z as described_ n the application for
Disposal System Construction Permit No. 14 41 Z dated��
Provided: Construction shall be completed within 4%re 'ars* e 4ate of this permit. All local conditions must be met.
Form 1255 Rev: 5/96: A.M.:Sulkin Co. Charlestown, MA Date - !` ward of Health