HomeMy WebLinkAboutApp-Permit-ComplianceNo. �C—( (p" I �(/ :
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Board of Health, A&mou nl- , MA.
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�ff APPLICATI N FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT
Application for a Perfntt to Construct( ) Repair# Upgrade Abandon( ) -Attompletesystem ❑ Individual Components
Location e YamOwner's
Name
•etjAe� st
Map/Parcel# 2�
Address
IIQ 0.
Lot#
Telephone#
Installer's Name i 's 1Cl , ta-6h
Designer's Name
Alwiel`
fl6W ti
Address sqj- y
Address
Telephone# _ Z..6(lys7
Telephone#
«-
Type of Building �lA ` - Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. requi ed//) gpd Calculated design flow 2S Design flow provided 335 gpd
Plan: Date b Number of sheets / Revision Date
Title % �,
Description of Soil(s) Z & J
Soil Evaluator Form No. 195T7 Name of Soil Evaluator bfiffl P ! Kdkr ate of Evaluation IDA
The undersigned agre o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a ee nc ce the system in operation until a Certificate of mpli nce has been issued by the Board of Health.
Signed Date I
Z" Inspections 17-'
No.t��IC""4(c?
COMMONWEALTH O SSA.CIUSE
W. 7�
b Board of Health, ,/� 07A MA.
CERTIEI� �� COMPLIANCE
Description of Work: ❑ Individual Com onent(s) �1 Complete System
P P
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired
by: 0 C. A V c P "[•j; ( .
f. .�►E
ef � t�
o ( fit
e A • andoiY e'd
has been installed in accordance with the Provisions of PO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approved Design Flow-J(gpd)
Installer N , kwj r--) ,, ZA �7
Designer: Tou✓,,dPW— L-tJ)61t4(-Clll-&Inspector: ate: ✓4 '�� 1.111
The issuance of this permit shall not be construed as a guarantepdat the system will function as designed.
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No. ��ii 17C�M.�(� i1; -
U i (� N •S �C !a � . FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL,, -SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( )
at & Me i er, Sf
Upgrade IN
W % Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within threer of the da e of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health -