HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6G WD C - Ib -Gj?2`-(FEE
fi llavIlte, ��% (J" !✓°"` /� � // �s �� �/'
COM
Board of Health, �r�(�`'Ic,1 jT4 , MA. C
APPLICATION FOP, ISPOSAL SYSTEM CONSTRUCTION PERM, IT
A plication for a Permit to Construct( ) Repair( Upgrade( ) Abandon O - ❑ Complete System ❑ Individual Components
Location
Owner's Name C G
Map/Parcel#
3 -7 3
Address �U ?Y2— erowu^
Lot#
Telephone# o G`
Installer's Name
�WS/-�n-r
Designer's Name
Address
!✓m J-(, 016-, 101A-
Address
Telephone#
/fdit f 77 3Y%l
Telephone#
Type of Building 21 ti&4 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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
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 place In in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �-
Inspections
No.-fir'—0-9S214 !� ! '.Jr��''! J 7 �V FEE
CO �'I®& Off' MA/I SSAC UST
Board of Health, , MACERTIFICATE Of COMPLIANCE
. fir'
?�
Description of Work;Individual Component(s) ❑ Complete System
The undersigned here y certify that the Sewage Disposal System; `Constructed ( ), Repaired Upgrad�e-d�( ),Abandoned( )
by: -e/2&,-25-ice=
at —rz 4 { (24?2- i -gin
''has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Z4' -5 k, dated Approved Design Flow (gpd)
Installer ;A A-axl lel
g P N�i (_ �/ rf r
Designer: ""`r Inspector: >r`v Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 414—t 16 -96 2 (�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, )h d11 T i`it , MA.
DISPOSAL SYSTEM C®NSTRUQION PERMIT
FEE a 5C
6" (x.35
Permission is hereby granted to; Construct( ) Repair 4Upgrade( ) Abandon( ) an individual sewage disposal system
at i Z.A -t C? 6 g CY-jaM 04 t.4 LA tj Q- as described in the application for
Disposal System Construction Permit No.�-f£W dated.
Provided: Construction shall be completed within three years of the date of this'ppr it. Ali local conditions must be met.
_ iY
Form 1255 Rev, 5/95 A.M. Sulkin Co. Charlestown, MA Date 1 r Board of Health