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HomeMy WebLinkAboutApp-Permit-ComplianceNo. - - �/�4�%`C G 1.4 %�� I /� d• FEE COMMONWEALTH OF MASSACHUSETTS k NO, Board of Health, Y181 , MA. 1 VR ®R. DISPOSAL SYSTEM CONSTRUCTION PERMIT �atir,a�°it tocepair( ) Upgrade X Abandon( - Complete System ❑ Individual Components Location -- 5im p5olU, A\1-1=-, Owner's Name tme&r/./ 6tgm G/�l L))VPr5 Map/Parcel# `� Address - Lot# ✓1-D1NG %%©. 2,1 or W Telephone# 5168 374 _ 6�'Q Installer's Name g/' /A/V C, Designer's Name. Donald W. Monceviez, P.E Address 17��5� �,�A ty.7� N Address Civil Engineer Telephone# 50* '776-04-4Telephone# 40 Street West Denanisnis , MA 02670 Type of Building R,E 51 DO',014T'114 - Lot Size sq. ft. Dwelling - No. of Bedrooms J, 00-51&A-1 -5774AV#9'RD 3 i5S Garbage grinderkjQ Other Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (mina required) 3316 gpd Calculated design flow � Design flow provided -34-1 gpd Plan: Date p� Td/ •77 Number of sheets Revision Date ,7AA!, ,;� �5,A6/7 Title T J D O -,Sq Ail'- i oz y �j��7�/� �' 'G)'�R Pe Description of Soil (s) ��.�% �i�-/q A -r ,,rr�� �r ,rr Soil Evaluator Form No. Name of Soil Evaluator D. 141,/� A�/ eWCVI CT Date of Evaluation kAi4 /U®R 8,= -AT -e 4AU2 Lucy -'50-r© 35 Wlo</,us o" ,.55 AIA eP16 Cad, ,-2.3 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es tqi not to plac Zisys m in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ,140 c-2-3 A 0 / 7 Inspections No. bq.FEECOMMONWEALTH Of MASSACHUSETTS V,51 Board of Health, �[�i.i AV1A. CERTIFICATE Of COMPLIANCE �U .� s Description of Work: ❑ Individual Component(s) Complete System UA O� The undersigned hereby certify that the Sewage Disposal System; Constructed , Repaired ( ), Upgraded , Abandoned( ) by: at S.S, S/MrspfuVAW,r-1- has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and t pproved design plans/as-built plans relating to application No. l��! 7227 dated. . Approved Design Flow (pd) � d Installer �T".� t_f'� _. _1` sd'r� /_. 4 Designer:/ I !^�r1/t (''7'Inspector: Date: The issuance of this permit shall not be construed as a guarantee that a system will function as desigted. No. FEE - " COMM®NWLLTH OF MASSACHUSETTS f� Board of Health, �Tll� , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Cojjnstruct(°j /Repair( ) Upgrade �< Abandon( ) an individual sewage disposal system at e ' - rte "��.,e r i`�' •� t9RmeDC ,i as described in the application for Disposal System "Construction Permit No. — dated Provided: Construction shall be completed within three years of the date of this pe it. All local conditions must be met. Form 1255 Rev. 5/96 A.M.�Sulkin Co. Charlestown, A Date (99 - ` Board of health �•.! <L" 1A/J'te./i7.4♦ i/e°'i?��i L+4•'�i[ �3%� /iJ O i� f' _`'%. ,