HomeMy WebLinkAboutApp-Permit-ComplianceNo. �" �10-6j'1: iG "/ACL""T � �� l ���
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COMMONWEALM OF MASSACHUSETTS 2) o-7
Board of Health, 7�.b , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CO STRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(Abandon( ) - Complete System ❑ Individual Components
Location Cap�, f3yC o'n s
Owner's Name
�tel-� wbre colk S' /h
Map/Parcel#
Address .7 L4
OL 1 417 con 9,11
Lot#
Telephone#
n6t r?�
�,,,�,(
Installer's Name 51 ``S (W���' C"' tW
Designer's Name
Cy 3 oL
Address d13
Address
Telephone# 7)
Telephone#
Sat S l
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
4.�
No. of persons
Lot SizeA sq. ft.
arbage grinder (A/0
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) � 3 b gpd Calculated design flow 35 Z` • Design flow provided 3.5-2
Plan: Date 4W;Ott, Number of sheets I Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS c'�i2f� /O U
Date of Evaluation 6— Z 9—
The undersigned a test n�stall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees of to pl the to o until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �G 7
Inspections
No. b o't� Dc ~ ! (c,-02-11 FEE 'f' 1!55-, 00
COMMONWEALT14 Of MASSACHUSETTS -4- -?m Q-
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Ja Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.(' , Abandoned ( )
by:
at
(111% (Afolk'") C- c, � ) !
-i G" r., rv4 Y, ro I1 v1 -,., C 1 !c`r I-, t, ( S CY..c i � fti rf-) r 4"
has been installed inaccor ai e with the Drovisions o 10 CMR 15.00 (Title 5)and the a ved design plans/as-built plans relating to
application No. (� dated 7 f Approved Design Flo 4i72# g d)
Installer 1,lelcwev 46t
Designer:yl V1Inspector: Date: fa
_
The issuance of this permit shall not be construed as a guar ee that the system will function as designed.
or r oc- LICIDoc-( co0r,000crew, :<.c,o�r, cuc.<,uo0ooc nc c^000ee-c,poi eco cC,- Inco-oO��Cor,r�jo',Ic
No. U k -I Dc - h �_�- FEE 155 o 0
COMMONWEALTH Of MASSACHUSETTS
Board of Health, %iO U734
�-
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgraded Abandon ( ) an individual sewage disposal system
at -7 �o � in (rn O ly,; L-1 r)) as described in the application for
Disposal System Construction Permit No. IG —k2 '- dated
Provided: Construction shall be completed within4k-r-�s.of the date of7t)
ermit. All loc conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date
�rh Board of Health