HomeMy WebLinkAboutApp-Permit-ComplianceNo bW-DC- (a40G0? b6d 'K C�4
% 4e CONI MONWEALTII OF MASSACHUSETTS
Board of Health, "le)L DL" , MA.
FEES:
C. -0V33
APPLICATION FOR DISPOSAL: SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System C3'Individual Components
Location VCJ aj
PA
Owner's NameEd
JV✓d
Map/Parcel#y 4
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Address00& re
f �e��*,
Lot#
Telephone# 7Z�. '�
- 1751
Installer's Name n�-.
Lal C
Designer's Name
Address 216o ev-ra
4 . et,
—cern Ad,
Address
Telephone#- � � .
�). `
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No, of Bedrooms 7 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 ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
OF REPAIRS OR ALTERATIONS i aCP- 1J
/ 16' 1. r,4t'S - .�W ` x
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees
�,ton t top ace they system in operation until a Certificate of Compliance has been issued by the Board of Health.
$ X14" , I:"-�rJ3:-Q-W+ /! e. W r
Signed :[..� �l'tC. Date �`� ` �• "' �4
Inspections
No. 60# G"'t�' �O�q
� ��, �O��ON�yl
LTII �� �����IILJ���T�
6
Board of Health �j A -at MOt -TU MA.
FEE_ 5,00
c 400-73p;
CT, ICAT�E Of COMPLIANCE � �
_'
Description of Work: M1 Individual Componef t(s) �'' Complete System
The undersigned he certify that the Sewag :Disposal System; Constructed ( ), Repaired YK Upgraded ( ), Abandoned ( )
by: J�o .8 s &, t' (*... L YIc
at
has been install da cl' h efr
vi�ons o 310 CMR 15.00 (Title 5) and t e approved design plans/as-built plans relating to
application No. /h ` dated '/ Approved Design Flow.�(gpd)
Installer tom' 4ti� (S�Df�#i1�_. O1112—
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No.bRDC-110-tO(O0� FEE
COMMONWEALTH OF MASSACHUSETTS ck4- C.) 0-7 313
Board of Health, { B y[j j , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
G- s 1, 1 t--� I
at
Disposal System Construction Permit No. ,—, dated
Provided: Construction shall be completed wt tont three years
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Boar
d
Repairvf Upgrade( ) Abandon( ) an individual sewage disposal system
Uas described in the application for
/ o a� of this pe �mi-Mllocal conditions must be met.
of Health