HomeMy WebLinkAboutApp-Permit-ComplianceNo. O �C-�r, V T lt-V7--00 fo *7 0 FEE 55.OD
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Ydf mo M MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade AbandonO - Complete System 0 Individual Components
Location 38 't yi Q
Owner's Name • Z
Map/Parcel#
Address j 8 114 G 1 t h A/4
Lot#
Telephone#
Installer's Name vsSe� G
Designer's Name, r n "nuc ��•
Address g S �� G /14 0 l,,wlY-
Address
Telephone# 59 - _
Telephone# 9 29
Type of Building S., Ine IL '% Lo Size b -7 0,/ -q sq. ft.
Dwelling - No. of Bedrooms - 2- Garbage grinder( )
Other -Type of Building No. of persons Showers ( ),�Cafeteria ( )
Other Fixtures
Design Flow (min. required) a/ / a gpd Calculated design aflow 3 3 49 Design flow provided gpd
Plait: Date fa�Number of sheets eG Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator PDate of Evaluation
r
DESCRIPTION OF REPAIRS OR ALTERATIONS 4 IA H e // I A- X 5A_�?� Y"►
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nto plac the s m in p a " until a Certificate of Co plian a has been issued by the Board of Health.
Signed /Date
Inspections (.;-, sT% ,tc
i
No. `eC_Ib-$�'® °�� r /�tFEE.01
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , MA.
ERTIIFICATE Of COMPLIANCE �,-�'.� � r�C.P,� ��' 9
Description of Work: ❑ Individual &mponent(s)omplete System
The undersigned hereby:certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �bandoned ( )
by: //Qt p c- 5 LA)a, 5e --P- V o CC-
at r 1
has been installed in ac or a ce with he rov's ons of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No/ dated ��. A proved Design Flow:�6(gpd)
Installer M, kkdv
Designer: > h Inspector: AW Date: f/
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
No. �C_—`�—�ica('J d-6L14j,5 tAjJ-V Y FEE 00
COMMONWEALTH OF MASSACHUSETTS 44 3 0-/(0
Board c f Health,Viu2m b Uzi$ MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ),Repair( ) Upgrade(-. Abandon{ ) an individual sewage disposal system
at I W 'as described in the application for
Disposal System Construction Per No. �, dated
r�
Provided: Construction shall be completed within s of the date of this pee ''t All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date -..� - Board of Health ��