HomeMy WebLinkAboutApp-Permit-ComplianceNo. ,)-7 -ao a D 2�
OoO-D&642-72 COMMONWEALTH OF MASSACHUSETTS
77 Board of Health, ee1T� , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTI
Application for Permit to Construct( ) Repair( ) Upgrade LAbandon ( ) - ❑ Complete System
FEE �b�PQO
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ON PERMIT
Ili ndividual Components
Location Q<9 Ow, -
Owner's Name
Map/Parcel# /,:�
f orf— 0 o26 1)
Address&.imeraha4+- - q
Lot#
Telephone#
Installer's Name IJk l �Ot—acfo(s �M
Designer's Name. S4e-p6PI f4. ftoLcu5
Address 3i3 00 K-4rn 0 nlMfi
Address() O (,_ S , Dzonl S p
Telephone# a)8 -
Telephone#
Type of Building 1&ts, (�Sf-��1 O -L Lot Size sq. ft.
Dwelling No. of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) C) gpd Calculated design flow
Plait: Date ] _ Number of sheets
Title Pte- '!- s f'4 f n " OL clad"t n a
Design flow provided gpd
Revision Date
Description of Soils) et Q! Ski Sa `l1 J
rt
Soil Evaluator Form No. Name of Soil Evaluator ��'i' flI)P!� ctLs Date of Evaluation Jr 1& (o
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 tc -th operation until a Certificate of Compliance has been issued by the Board of Health.
Signed i Date %o -)p
r
r
Inspections
i 1 COMMONWEALTH Of MASSACHUSETTS
Board of Health,---�t�UT7-k , MA.
CERTIFICATE Of®��.�NC A
Description of Work: udividual Component(s) (J Complete System ".
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( )
by:
at
has been installed in accordance with the provisions of ,,10 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. r > dated' %' Approved Design Flow -(gpd)
Installer 1
Designer: (1 "UP Gt S Inspector: '' C Date:
4/- , _ }` j4
The issuance of this peanut shall not be construed as a guaran that the system will function as designed.
FEE— 4.
'.
77 COMMONWEALTH Of MASSACHUSETTS *100(09
Board of Health, \!"M 0 M , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Per"mission is hereby granted to; Construct( ) Repair( ) UpgradeAbandon( ) an individual sewage disposal system
at (n0 Kercinwit_ as described in the application for
Disposal System Construction Permit No. 1.4 /, dated
Provided: Construction shall be completed within QZ� e date of this permit. All local cogiditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 6 - Board of Health C�