HomeMy WebLinkAboutApp-Permit-ComplianceNo. l LI ^ FEE
COMMONWEALT14 Of MASSAC14USETTS Ck"G 3 7L
Board of Health, 7, 4 F—M 0 LM4 , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
V cAA ') v rJ L j
Owner's Name
Map/Parcel#
"—
Address 58ILd
g
Lot#
Telephone# L) _ t�
_ , L) gy LIT,
LIT,
Installer's Name
Vim- r -r & � Co
Designer's Name
AddressF?
Address
Telephone#
('
Telephone#
Type of Building
Dwelling - No. of Bedrooms _
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
COOCE & ke—j t—f� t s,<-- Q
gpd
»`k
all FIF1,0>9 :rqpu -rd P' r of
ti2A) 2� er � ,.� 'I) 66822 p, no e -,,j -n" 7-4) ������� "off 6�rtdg,
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 / tem m j9pAeration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Oma! 1Z�
Inspections
COMMONWEAL114 Of MASSACHUSE0(0376
Board of Health, y affl o (Z734 P
CERTIFICATE Of COMPLIANCE l cX -t-
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (io', Upgraded ( ), Abandoned y-
by:r/� e ms,/ o U CL C c �� C
at `7 t.�1 i %� t` .'i i -a h A i is %V
has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `d' tt ' _ dated of i Approved Design Flow (gpd)
Installer AL, o}
Designer: Inspector: r Date: } —0,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. a U FEE 4 - DO—
COMMONWEALT14®F M ASSAC14USETTS (�
�x c.
Board of Health, VA t2ly! D U MA. M `•
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(%4 Upgrade( ) Abandon( ) an individual sewaeedispoD
at -} ` - A 'Vt� nK, I /Q as described in the application for
Disposal System Construction Permit No. I -/")-J ,dated of fit✓
Provided: Construction shall be completed within three years of the date of this errQmit.. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date a -I Board of Health `''