HomeMy WebLinkAboutApp-Permit-ComplianceNo. Ip7oti-D C'((,o' 839 �0
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®MM® LTH Of MASSACHUSETTS
Board of Health, -M d t1} , MA.
FEE (J u 0 0
XVP I�ATI®N FOR DISPOSAL SYSTEM[ CO TRUCTI®N PERMIT
pplication for a Permit to Construct( ) Repair( ) Upgrad Abandon() - Complete System gludividual Components
Location P,I}-r4Kov��
Owner's Name ' l
Map/Parcel# y -7 -
Address
Lot#
Telephone#
Installer's Name 41 S
Designer's Name = -
Address �11 Ji� tGG�
Address Q 13ax L12-fS 444c/f4-
Telephone#
Telephone*L3 - , l
Type of Buildingi�c%a 5 r /'!9 �'�L°� _ L.ot Size -:PJ (0 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 5-:570 gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No,
Name of Soil Evaluator
Design flow provided -5616 gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS OSf(/ / V ,6� 2 "o c
The undersigned agre'ek to ' tall th above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not top ac " a in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Wit/ ! �— Date " /6
0
-'�
Inspections
No.
w�JEE T 50.,. _
C6MMONWEALTH Of MASSACHUSETTS). p,
Board of Health, ,MM.
f CERTIEI TE OF COMPLIANCE � ��� i5,-'16 7&4�
Description of Work: ❑ Individual Component(s) +6 Complete System ox/
The undersigned,ilereby cer 'fy that the Sewage Disposal System; Constructed ( ), Repaired (V Upgraded ( )> Abandoned ( )
by: �`�d,) 1`' �
has been installed i /accord nce with t e ro�7stCons of 10 CMR 15.00 (Title 5) and the/approved design plans/as-built plans relating to
application No. iP dated "'" / �� Approved Design Flow ��C� (gpd)
InstallerOL J'/
Designer: V `•/ Inspector: Dater -3-1-6
The issuance of this permit shA not be construed as a guarantee that the system will function as designed.
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2- / COMMONWEALTH OF MASSACHUSETTS �
V� Board of Health, ` 49:. O Vr 4 , MA.
DISPOSAL SYSTEM C® UCTI®N PERMIT.
Permission is hereby granted to;
Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 5..J Ft �,,� (z, U..1 T
as described in the application for
I
Disposal System Construction Permit No. b �-"� , dated
Provided: Construction shall be completed within thrar-=axsof tthe date o{f.,this erm,Alll local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown MA ate j '- Board oealt�-�`,'�1