HomeMy WebLinkAboutApp-Permit-ComplianceNo.
COMMONWEALTH OF MASSAC14USE
t
Board of Health, -�nLQAO MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRL
Application for a Permit to Construct( ) Repair( ) UpgradeAbandon ( ) -omplete c
FEEy l
G�2' C9
Location J u Q S
Owner's
Owner's Name J.) InA 6 F
Map/Parcel#
Address
Lot# 4 L4
Telephone# S _Zt— 6 41
Installer's Name Q06e ` l R . r�� G' Co • <X _
Designer's Name l U� �
Address .Q - F, �i�%tdk !"i
/� _�� ii
ddress R 6 •LX=)( L1%Z (�,beo is ti
Telephone# a -i —(, a_ C
Telephone# X50 —36q— q
Type of Building Lot Size �3 } �' sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) �Cafeteria ( )
Other Fixtures''
Design Flow (mi re uired) gpd Calculated design flow J ?,r .) Design flow provided gpd
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s) (-
Soil Evaluator Form No.
J —L -os" ] 1 l , (— ►'((�(1 L c�N - /v o r
Name of Soil Evaluator A*.,I 00' A 3 f OMe— Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS � l I L50x> ("a�r� -. -rA.OK .
The undersigned agrees to inst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to plac system m* peration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date C11i ')b
Inspections
ik
No. Dc — i(0-10405 - ;
Board of Health, _�%ARjM0t i , MA. �V`ZOI
CERTIFICATE Of COMPLIANCE
Descr!?t on of Work: O Individual Component(s) -! rComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ; Repaired ( ), Upgraded,;,-, b ndoned ( )
hvc
at
has been installed inaccordance with the "rovisions of 3 0 CMR 15.00 (Title 5.) and the a proved design plans/as-built plans relating to
application No. — Z� dated Aa Approved Design Flow (gpd)
Installer c ) .�
Designer: k4$5 V--(yo'Zei+lG-1tJ6(-li(t krispector: LZ Date:
The issuance of this permit shall not be construed as ra guara the system will function as designed.
No.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, NJA �Wa# W , MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( )
at c>1.,r7,1.�C1A--) I C.>rC`� 1<,f -X
Disposal System Construction Permit No/Z—////11 , dated
,,'Abandon ( ) an individual sewage disposal system
as described in the application for
Provided: Construction shall be completed within three years of the date of this.per .'t.�All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Dater `'Board of Health '