HomeMy WebLinkAboutApp-Permit-ComplianceNo.'9p#Pc--46 17,5v 7 R , ) -) 0-023Q;
FEE
2, COMMONWEALTH Of MASSACHUSETTS C*__r_ Lf to
Board of Health, �iui illi , MA. �" , %
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - ❑ Complete System , Individual Components
Location 1 ( CQb
( S ,�
Owner's Name
Map/ParceA
Address
b6 Q
Lot#
Telephone#
019 • Z, -7 LN_ 17
Installer's Name ��
�cav xtt® r,
Designer's Name
5 ±fpbtn A. jQ S
Address 14 .� b
(e C f 11C.
Address
Telephone# 6
I -OA
Telephone# d
Type of Building _t&C:y
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size
sq. ft.
® Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) a,30 gpd Calculated design flow Design flow provided gpd
Plan: Date I! Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS R o
7ZiG,/9
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree n t to place t in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections or PO
No. L� " t ( V
; FEE.. .
rl-
COMMONWEALTH OF MASSACHUSETTS
Board of Health, QUZW MA. (7-464 ~ ��
rrmirld- A r n, r rnmw v/v cir P*Vy T- /P' 6),ff �'7
Description of Work: Zdividal Component(s) 0 Complete System
The undersi tiedh reby certify that the Sewage. Disposal System; Constructed ( ), Repaired ( ), Upgrade ), Abandoned ( )
by
at i I rA0 ur3fl- r- hrmt -o n n_ 6 • �+' n i m /')f )`Fin
has been installed in ac°°rd,cewith the provisions of 310 CMR 15.00 (Title 5) and th pproved design plans/as-built plans relating to
applicati". ^"/:7'—dated Approved Design Flo "�=(gpd)
e r
Installer
g 1? "_- ! �' Date: %P/ �ea7 rr/lrlJ
Designer: , i Y N I Inspector: .�,
f
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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^.00OO,.Jt�JiJ J' C000 JU `QCO JJf;UOl7 �O;'J UG ��„iuOpf p:J Ut>C��i3O��.iL 10000C.00C _-'�01 nbCCJOJ0000CGUUpp r?i�U.00t .�O:?'O'ot OOVOO,G
No. 6p 14:pt;4'6 -V7 3 0 �� �� � cA v 9 -no (�•/ . � FEE �, ��0)6
COMMONWEALTH Of MASSACHUSETTS
Board of Health, 7-✓Z.d�l Ii�'� _ , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at (3 ¢ ' �- i� C f 1 /� " I �o E\ I) as described in the application for
Disposal System Construction Permit No t,^ - -, dated .-
Provided: Construction shall be completed within teWr-&�the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date"�/ . "%� Board of Health