HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 a7-374 --T 7 b 71
r 7-67 COMMONWEALTH Of MASSACHUS��
{� �T-Board of Health,
�✓�}f MO vel MA. IR
APPLICATION ICOR DI POSAL S ]1STLM C'U�1 STRUCTIO E
Application for a Permit to Construct( ) Repair(q Upgrade( ) Abandon( - ❑ Complete System
46-6,0-0
6?V7
Location
Al 114.1!t
Owner's Name 6 e
'p V4 1
Map/Parcel#
?6 7
Address
Lot#
Telephone#
Installer's Name
1, v ,
Designer's Name
Address
Address Bmf
Wlow
Telephone#
G� U s Q ��2
Telephone#
Type of Building 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) gpd Calculated design flow :3 � Design flow provided 5�6 gpd
Plan: Date -Z - 7-9-- / 7 Number of sheets _;L Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator /kr/fA ei.�',�ate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 7—,,4-r la, � [" � sAr
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to nottttoplace the system m operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r la -moo iGl i Date J'_ kfl-
Inspections
No. `O
0D C-17 - _3? qi
i -6 �
COMMONWEALTH OF MASSACHUSETTS
Board of Health, *ftoyn4: MA
CERTIFICATE Of COMP IANCE
Description of Work: ®(Individual Component(s)
The undersigned hereby certify that ig Sewage
by:
at
has been installed in accorda ce with the rov
application No. dated
Installer o !
❑ Complete System
System; Coi}structed ( ), Repaired ( ),Upgraded iandoned ( )
e- d
/FEE
1
4KC Ct 1pea4r
of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
/ Nproved Design Flow (gpd)
Designer: ���:(/'�?M f'�C'�i�l Inspector:_ Gf Date:
The issuance of this permit shall not be construed as a guar ar} ee that the system will function as designed.
No. i f'°j <.( 7 pCsTn FEE _ sC
COMMONWEALTH OF MASSACHUSETTS c4- 6,54 ('0
9
Board of Health, V"M MA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ), Repair( ) Upgrade ( Abandon an individual sewage disposal system
at (Z/
as described in the application for
Disposal System Construction Permit No. datedk-/7
Provided: Construction shall be completed withiu4hx@@-y� ofNh(e3date of this peymit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date fir/ Board of Health f