HomeMy WebLinkAboutApp-Permit-ComplianceNo. gl.D W� (� — ®®��,-2 FEE' W 00
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COMMONWEALTH Of MASSACHUSETTS
Board of Health, �I� C 1' + MA. kw� 64
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) - ❑ Complete System 4kndividual Components
Location ` to
Owner's Name
Map/Parcel# Co (3
Address /0,0&k V"�O llaualo
Lot#
Telephone# z/r5-- wa .- , 9-a
Installer's Name //�� r
(JU i� I O
Designer's Name Q tzdnj �'
AddressLafS
G Address q3
Telephone# %O?,39
Telephone#
Type of Building Lot Sizet s ft.
C V 9•
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers O, Cafeteria. ( )
Other Fixtures
Design Flow (�m� in.�required) y �U gpd Calculated design flow Design flow provided VS—Ls— gpd
Plan: Date- � Wu'�'+ 1 q. ao 1 Cl Number of sheets % Revision ate
Titlej,&
4 0
Description ofSoil (s) 'it � T, 1� b6bl %0
IF
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to ins bove described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not toce system in operation until a Certificate of Com iance as been issued by the Board of Health.
Signed _ Date-�
No. L'" f
(R _�� L COMMON �.T`1 OF FEE
MASSACHUSETTS EE r yrs
Board ofHealtla,�� l �'� , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 1:,11ndividual Components) ❑ Complete System �`"
�-C Lr'
The a der 'fined he.ebyc rtify at the ewage Disposal System; Constructed O, Repaired { iJ ade� d ( ), Abandoned ( )
by: / GC mm
at vjim
has been installed ii ccord nye with the p�visions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application o. dated Approved' Design Flow -(gpd)
Installer
Designer: Inspector: Date: _
The issuance of this permit shall not be cons led as a,gua_ tee at the system will function as designed.
No. FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, Yplem 0 OT , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an indiyidual,sewage disposal system
at as described in the application for
Disposal System Construction Permit No. , dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date Board of Health