HomeMy WebLinkAboutApp-Permit-Compliance151
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.No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y % MO , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct pair( ) Upgrade( ) Abandon,( ) - ❑ Complete System O Individual Components
Location Jr[Sold /V1 owl e
Owner's Name Pot/ I �-- �r
Map/Parcel#
Address _
Lot#
Telephone#
Installer's Namdowri e
O�,
TzO
Designer's Name s1q
y �
Address3 ce
Address q2q� �®Vo*
1 I
Telephone# 1' j; C(_ .Z (h
Telephone#
Type of Building HPOrrl C Lot Size -3C;) ,q. ft.
Dwelling -No. of BedroomsGarbage grinder
Other -Type of Building No. of persons Showers (' ), Cafeteria (
Other Fixtures.
Design Flow (mf'n,f equired) ti O gpd Calculated design flow Design fiowprovided gpd
Plan:' Date �S / (l1 /` Ci 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 undersigned agrees to install the above described Individual Sewage 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 Comb fiance has been issued by the Board of Health.
Signed Date I� % Ci
V,
No. 3� �"(�i FEE
COMMONWEALT14 Of MASSACHUSETTS
Board o f Health; _ [l , MA.
CERTIFICATE OF COMPLIANCE p
Description.of Work: ❑ Individual Component(s) Complete System
13
The ;undersigned hereby certify that the Sewage Disposal System; Constructed (.,,)z Repaired ( ), Upgraded ( ), Abandoned ( )
by: JQ
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) afficl. the. a proved; `design plans/as-built plans relating to.
application No. dated K 4.. ,Approved Design Flow (gpd)lied (0 d ,
Installer ! - ),A k t,4 I `V
Designer:1 ?(>i�liJ ( QC— f- �•11�, Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system. will function as designed.
No.,l) C t -1�j -'�.k7 Vl^t� 1 Li 1� 1�3 i �� FEE A=` -=Z -F/
COMMONWEALTH OF MASSACHUSETTS
Board of Health, n (" , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gran ted to;; Construct(vf Repair( ) Upgrade( Abandon ) an individual sewage disposal. system
at 15%7 � V as described in the application for
dated
Disposal System Consquction Permit No. ,_
Provided: Construction shall be completed vvifhit r, ef-'th�date oflthis permit., All local condittpxrs'must be, met.
f ,
Potm 1255 Rev. 5/96. A.M.Sulkin Co. Charlestown, MA Date_B.oard of Health