HomeMy WebLinkAboutApp-Permit-Compliance31�7 FEE i � Od
No.
.r
COMMONWEALTH .ILTH ®F MASSACHUSETTS 01222 1 U
Board of Health, ��A a 0 V114 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
9
Ap lication for a Permit to Construct( ) Repair( ) Upgrade (^ Abandon() -
U)
LlComplete System Individual Components
cation
Owner's Name
ap/Parcel#
9 0
Address
Lot#
S„
L(C-rfA
Telephone#
Installer's Name
iC (26WST- 0
�r.�
Designer's Name I n
Address
Address
Telephone#
Pt- 08 90Z
eel
Telephone# �
Type of Building Lot Size sq. f
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min required)
Plan: Date
Title
gpd Calculated design flow Design flow provided _ 4.5" gpd
Number of sheets / Revision Date
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS See- / 411
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to t to place the1 tem iation until a Certificate of Complice ha been issued by the Board of Health.
SignedDate
Inspection (G 3F, G'
No. /-,51—! /..� E6�JEFt �J 00
COMMONWEALT14 Of MASSACHUSETTS 04 7 -�-� �/Y" � � 22--2-?8
Board of Health, 1hgg.1M0tJ'71-I , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: endividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:�
at R ✓ i (t s LA A �-
has been installed in accord ce with the
application No. 7 , dated J
Installer f)c)0A -X) Pe1ftt E Q ,.5__
I CMR 15.00 (Title 5)
Approved Design Flo
Designer: V! CApe' Inspector:
Date:
The issuance of this permit shall not be construed as a guarapt/ee that the system will function as designed.
led -
No. a 1 " �//
4
COMMONWEALTH MASSACHUSETTS
Board of Health, Yj ►M4
FEE- _-'
Ck* 2-2.2-%8
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( _Abandon( ) an individual sewage disposal system
at W A),i cl li ea, � 1-c".j... S , t(c-r "0'J/� ` as described in the application for
Disposal System Construction Permit No. j — , dated V/ %��re
Provided: Construction shall be completed within tlzre �o die ate of this pep
. l local conditions must be met.
,,_`Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date oard of Health