HomeMy WebLinkAboutApp-Permit-ComplianceNo. if-bG'
COMMONWEALTH OF MASSAC14USETTS
Board of Health, 7A 12 JA/I B l rr* , MA.
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APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct(X Repair( ) Upgrade( ) Abandon( M/Complete System ❑ Ind,,dual Components
/!-,-J-,F c 71) 14
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Location /5'.3 /✓sem 7�i IV,9 ,J .S�Yt e l--
Owner's Name =tee 2 ra r %lace:
Map/Parcel#
d 13
Address 4 111 ftvep,
d XVaAr C7'
Lot# Z
Telephone#
Installer's Name
6�1/ji'ffz-�e feoc/✓t�r �d �ivC. Lvh
Desi ner's Name
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Address pp.
goX /07/D Waw e,'-
Address Oo. gs /d
Jz c, /7P,u.c�ir
Telephone#
Telephone# 5 QoP- 36,? -
Pl-?A
Type of Building Lot Size /�� �J % sq. ft.
Dwelling - No. of Bedrooms -3 Garbage grinder( )
Other - Type of Building No. of persons Showers (v, Cafeteria ( )
Other Fixtures 'i'If k
Design Flow (min. required) -73 D gpd Calculated design flow • 73 G'
Plan: Date Number of sheets
Title Peg h [ c/%✓ f�i+. � r sf '"
Description of Soil (s) _
Soil Evaluator Form No
6'70
a cJ / N1 t a'. u �r 4,,u ,Z—
Design flow provided �e gpd
Revision Date
Name of Soil Evaluator ff@PXty Date of Evaluation 11711,6
DESCRIPTION OF REPAIRS OR ALTERATIONS Ald-v cLw h•c "sfeek7
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed d� Date 4 9/ / G
Inspections
No. "� '1 o ' ' /G1� FEE f Z, 00
COMMONWEALT14 OF MASSAC14USETTS �6�1645H
;> Board of Health, ,
CERTIFICATE Of COMPLIANCE , y�
Description of Work: ❑ Individual Componelt(d). je Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed X, Repaired ), Upgraded ( ), Abandoned ( )
by: IA,)A,•I`-/e sy � pdree;••� � ✓n _ �"
at f's"3
has been installe in aecotdanW w'tl h g1 e p ,visions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. dated-;.Z1-/� . Approved Design Flow 349 (gpd)
Installer GSA, j%r' L6,01,r 74r
Designer: 174e i" Inspector: Date:
The issuance of this permit shall not be construed as a guarande that the system will function as designed.
No. 5 DC 5N8, WAIVEIN JP.5Che1 rJG FEE JSS, 00
COMMONWEALTH OF MASSACHUSETTS 36q
Board of Health, V 1Ng)t1T A , MA..
DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Permission is herebygranted to; Construct(v/ Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at /f'j /f'IV, /4 IA't "`l "rkee /a -// as described in the application for
Disposal System Construction Permit No. , dated'! .2
Provided: Construction shall bcompleted w> leis -of the date of this pemit. All local c ditions must be met.
Foam 1255 Rev. 5/96 A.M. Sulkin Ca Charlestown, MA Date Board of Health