HomeMy WebLinkAboutApp-Permit-ComplianceFEE boa
COMMONWEALTH Of MASSACHUSETTS c if 31"7
f I®C� 3a 1
`���� Board o Health, ,
,APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Iin foPt to Construct( Repair( Upgrade(�Ab
andonO O- omplete System O Individual Components
V
Location 92 rW r r(e h 5tr?�
Owner's Name EdvvarM i LiSm V61ty
Map/Parcel# 34 151Address
92 F- CI( (e e h SIMf
Lot#
Telephone#(o b)
Installer's Name b i B G X C a V afi O h
Designer's Name M p r a n Endineertaq
Address 14 Tubbvlqw
Address f. 0 IB 54 ( L h
Telephone# bo � - y l 1
Telephone# • `1 3 .2 ? 7 5
Type of Building IN L JI (A
Dwelling - No. of Bedrooms
Other - Type of Building _
fia
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) �3� gpd Calculated design flow 3 Design flow provided 3 3 gpd
Plan: Date 5 I 1 I i ( Number of sheets � Revision Date
Title
Description ofSoil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation a
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further Meto ot lac a system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 2 Date 1 a iP
Inspections / L LF
11 04
COMMONWEALTH OF MASSAC14USET46 T
Board of Health,MA. ,fy� �10✓""
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) O'Complete System
The undersigned hereby certify that the'Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (i Abandoned( )
by: �� n�!(VGJ�(i1 t
at
has been installed' accordance with the provisions of 3r10 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to
application. No.; If -/? C _'dated ) _� ) ___/( ,. Approved Design Flow (gpd)
Installer r",( _X -"L
Designer:' � f Inspector: ,"- !r ir' Date: 774 ,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 1'� 4 %t (tc b (� ! i% �` -)C f�sVA 11 ON FEE ' 06
7�- COMMONWEALT14 OF MASSACHUSETTS Y31 7
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (A Abandon( ) an individual sewage disposal system
at J-�l+r_Y"t1 ! ' ' as described in the application for
Disposal System Construction Permit No. lel) r/ 7 , dated 7 •��
Provided: Construction shall be comple(ed within thr-@@ayt-ars-jQf the date -9f thispex rt, All local conditions must be met.
.,q
% Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA / Date Boar of Health
/ �'' .�f r.e 6;� Sze-`'..
L c 1�/eta 7 ��tt' �s tai ?