HomeMy WebLinkAboutApp-Permit-ComplianceNo. D�tSYC� `o- O -Z-39 /V ,b TR —) -? ` 0 00 / pe FEE
7 COMMONWEALTH Of MASSACHUSETTS 2118
Board of Health, b ltcw , MA.
APPLICATION FOR DISPOSAL SYSTEM _= ST��T�T��N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade/Abandon( - Complete System ❑Individual Components
Location
AA t -C
Owner's Name 0 -v- h ► 0-P
Map/Parcel# a
OZ /
Address 31,c", %Zv,% lit,
Lot#
Telephone# -Le ) 3,---� % ply 2.Ur
Installer's Name ��l d
6\c,,rA/d C c p(
Designer's Name le -`'t9 /e'l Cg G
Address a3
Address /JO y ;tSc� 1-t--67
Telephone# SC(C -
Telephone# S cd -''7 — S 7 001
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
gpd Calculated design flow
Number of sheets /'
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided �3 gpd
Revision Date
Description of Soil (s) Set' S' -j j L! ,A
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 3 v 7 �� ti -1 Q » L�°Y► /� 0L�.,P/�J' N,�c
The undersigned agre to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o pl a the tem ' o mil a Certificate of Compliance has been iss ed by the Board of Health.
Signed Date rJ `�
r � �
Inspections
No. ij C.- �,._Q���'�' FEE
r 7C®I�[MONWEALTH Of MASSACHUSETTS 44 2A I �3
Board of Health, -Mi, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (.oAbandoned ( )
by: P 116 8 r.. 7'ho cS Cc n S)
at — 0d1b 1/,& r- Y2rc, d In.'..A S y_- f_
has been installed in accordance with -the rovisions of 3;0 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. dated i/ Approved Design Flow (gpd)
Installer t= / i i C old -1.11,11-1 e�112 f
Designer: A&,M 15i.)� CQ tj I'll 6 C Inspector:)h.a 3s;tp �.. (1.i�! Date: I, ") i ) I I Ila
The issuance of this permit shall not be construed as a guarantee thatthe system will function as designed.
No. C_ (U .'-ui� i FEE
f� �1 7 COMMONWEALTH OF MASSACHUSETTS
Board of Health, '406`O`%M, MA.
DISPOSAL S STE ���15TRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (-< Abandon ( ) an individual sewage disposal system
at . i, l- jl-�4 Y, %)- c c-, d r t t� ° i ., c, . "� as described in the application for
Disposal System Construction Permit No. , dated 7-14—/56.
Provided: Construction shall be;completed within IJ=&yrs o�'the date of this permit. All local con 'tions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date s Board of Health 1�