HomeMy WebLinkAboutApp-Permit-ComplianceNo's go 4-D c -[9'-6y31
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CO COMMONWEALTH Of MASSACHUSETTS
Board of Health, lii( r' naj:1 q MA.
APPLICATIONFOR DISPOSAL SYSTEM CONSTRUCTION
AUG 1 V-019
TH DEPT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System ❑ individual Components
Location balved
Owner's Name
Map/Parcel#i'1j'�j •
Address
Lot#
Telephone# 5M -362_-_799q
Installer's Name -r ( ' / +) Q
Designer's Name
Address I Z T
-�
ddress 13C _ (_ S -r fnp
Telephone# -
1 Telephone# ISM- toa j�fS yl
Type of Building P!1(�J _ Lot Sizer C) sq, ft.
Dwelling- No. of Bedrooms Garbage grinder
Other - Type of Building No• of persons Showers ( ), Cafeteria ( ).
Other Fix.aires
Design Flow (min. re aired) 0 gpd Calculated design flow 3 Design flow provided 3 7 gpd
Plan: Date Number of sheets _ Revision Date
Title
Description ,of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS .OR ALTERATIONS
The undersign agr es to install the above described Individual Sewage; Disposal System.in accordance with the provisions. of TITLE 5 and
further agr on t place tem ' ration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ..
j py
No�(. �" 1 9 -0q 3 ! FEF. 6�
COMMONWEALTH CF MASSACHUSETTS eo , d C1310�
Board of Health; Vrl 1,
"�,`MA.
`Vg
CERTIFICAE Of OMPLI1ANC
Description of Work: ❑ Individual Component(s) ❑ Complete Systet'l
The under:i ned hereby certify that the Sewage Disposal System; C onsa ueted ( ),Repaired O, LlpgradedAbandoned ( ).
r
at
has been installed iri" accord nce with the ro��sions of 310 CMR 15.00 (Title 5} and the:approved; design plans/as-built plans relating to
applicaticn o. lei � dated —. Approved Design Flow�(gPd)
Installer ,' x t r t
Designer: V l� J Inspector: sJ� Date:. 49 t
p guarantee that the system will function as designed.
The issuance of thLsr permit hall not be construed as a arante
No. 0 � (--I (O '014 31 � � y - -FEE i5YOO
COMMONWEALTH Of MASSACHUSETTS
Board of Health, _ MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
ted to Constr t ( ) Repair( ) UpgradeX) Abandon( ) an individual sewage disposal system
at
Disposal System Consti uction Permit No. (c -1 C�& , dated R.. -- �
as described in the application for
Provided: Construction shall be completed within three vears of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Dated ` - '�� Board of Health