HomeMy WebLinkAboutApp-Permit-ComplianceNo. 840 —0 —00 3 Q l ,% FEE^ oV
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17 — Board of Health, YAM uy�l�, MA.
PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
�P ati�fr a Permit to Construct() RepairXupgradjefAbandon
() ❑ Complete System ❑ Individual Components
U/
Location
Owner's NameI y '
Map/Parcel# 3
Address �g' o In t -
Lot#
Telephone# 603-- 30— & SS
nstaller's Name �'
Designer's Name t R,5 So N .�
ddress3 C1
_ o Address P o b J j a _
Telephone# .-
Telephone#
P
Type of Building
Dwelling - No. of Bedrooms _
Other Type of Building _
Other Fixtures
Design Flow (min. required) 330 gpd Calculated
Plan: Date �7 1 / ci 11,Numbr of sheets
Title - -- ---4` ' Aj _ P ,.
OI ' 1 Jy
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
flow
DESCRIPTION OF REPAIRS OR ALTERATIONS L-✓ ' !\G LU
The under igned
further a e
Signed
Inspections
No. of persons
Lot Size to ap/ __ __ __ sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow
Revision Date -
Date of Evaluation
gpd
f the ab e e ' ed Individual Sewage Digpos System in accordance with the provisions of TITLE 5 and
syste ' o don until a Certificate of om 1�ance has been issued by the Board of Health.
Date i ,1 /
Qkc
_
COMMONWEALTH OF MASSACHUSETTS r
` / 2 -e Jam ' / 0 cfi tc� S
Board of Health, 7( '�d1.rl _, ALt
CERTIFICATE Of C®MPILIANC
Description of Work: ❑ Individual Component(s) ❑ Complete System a 7 ft
The undersigned hereby certify that the Sewage Disposal System,' Constructed ( ), Repaired, Upgraded ( ), Abandoned ( )
by:, K M QV r
at a CQ
has been installed ijacc rdance with the 11rovisions of 10 CMR 15.00 (Title 5) a t e proved design plans/as-built plans relating to
application No. fl�yy^ dated aL.. Approved Design Flow (gpd)
Installer rl e -V C-�`a` G'cc % M t Q VjEL..L-
Designer: 614S sU/ e) i Y (...•a' c Inspector: V LI Date:
The issuance of this permit shall not be construed as a guarait ethat the system will function as designed.
No. lJ OH-Vc—1 .1L—FEE
rCOMMONWF-ALT14 Of MASSACHUSETTS die to -Z- G
Board of Health, 0r*_—, NIA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to- Gonstruct(
at N-Le-Zq P0--, ri '
Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
__j
Disposal System Construction Permit No. %�7_, dated.
Provided: Construction shall be completed withinrs of the date of this permit. All local cond'tl.Qps
must be met.
Form 1255 Rev. 5/96 A.M. ulkin Co. Charlestown; MA Date Board of ealth
On, l /47 24