HomeMy WebLinkAboutApp-Permit-ComplianceNo. 60VVDC -LS-f 210 Lf
COMMONWEALTH Of M ASS CIIUSETTS
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Board of Health,MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( - ❑ Complete System ❑ 1
FEE 55.00
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HEALTH DF_
Location
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Owner's Name 144qCjb0,qkX
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Map/Parcel#
Address 6
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Lot#
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Telephone#
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Installer's Name
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Designer's Name
Address
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Address
Telephone#
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I Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator `
Design flow provided
Revision Date
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no a the cyst eratio icate of Compliance h bee ued by the Board of Health.
Signed Date
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Inspections
No. &wx -t-5"'1 FEE . ®O
15-3 1 COMM ONWEAI.T14 OF MASSACHUSETTS
Board of Health, 2 I VI Q 1� T �-% , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System CJ J
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded ( ), Abandoned ( )
by:
at L�C'g Wt ND IN(s- 810.Q0k' r
has been installed in accordance with the pr visi?ns of 3101 CMR 15.00. (Title. 5.) and the, approved design plans/as-built plans relating to
- application No. I —�a dated rl ! Approved. Design Flow' (gpd)"
Installer
Designer: Inspector: -P Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �". p k-iDl, /4 cc W FEE
COMMONWEALT14 OF M ASSACIIUSETTS
Board of Health, 4RM 0V7 , MA.
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DISPOSAL SYSTEM CONSTRUCTION PERMIT 0 LA,
Permission is hereby granted to; Construct( ) Repair( IV Upgrade( ) Abandon( ) an individual sewage disposal system
at 49 WIAW ' as described in the application for
Disposal System Construction Permit No. r 3 , dated �J
P yided: Construction shall be complete&within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA ? Date 3 11 S Board of Health '