HomeMy WebLinkAboutApp-Permit-ComplianceNo..6 rfl>c- / >—
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COMMONWEALTH OF MASSACHUSETTS
Board of FTealth, ra,,-y1A, o tli—k M.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( .) Repair( ) Upgrade(g Abandon( ) - 8,Complete System ❑ Individual Components
Location �f y ��„�ri,ti, G
Owner's Name
Map/Parcel# 9 - 3 a ci
Address T"f
Lot#A- Z'j
Telephone#
Installer's Name+�+ ��� �
Designer's Name ��Q�ifi2 1l---�C,(AA.&
Address C-0, —\ Y,
Address Z �� t Crtr sS`�i 2 t� _ Cr. L
Telephone# >r-QZr LtCV -7t.5 C1 (j2q4,3Z
Telephone# %J-7-7 3 ( R- dz
Type of Building K ccl �Z711.�%`� ei-' Lot Size l V91-7 '�'- f ' sq. ft
Dwelling - No. of Bedrooms -e_ Garbage grinder( )
Other - Type of Building /� ! A' No. of persons Showers( ) , Cafeteria (
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 2213 Design flow provided .5 -2 gpd
Plan: Date -71(-Z-1 1'7 Number of sheeetss-.�g7s Revision Date `'
Title �Q %ee �� i'• Z �� S t^ -t `To G� Sal 1`�JL Y 1 1 cyv-, , ” 1
Description of Soil (40-=A LS `7 39' 9 L,5 3S —1 d 7 C- 1A , S` IA S�-� 6-+w (o (4
Soil Evaluator Form No. Name of Soil Evaluator eAe- of Evaluation <;) % f
DESCRIPTION OF REPAIRS OR ALTERATIONS 6!W Q44 1570 cj 4 � TYcu-4 t c.
0- 6dX A✓t 3 S Uva r f
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further apreto not to place the
/system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed i Date 7
Inspections
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COMMONWEALTH Of MASSACHUSETT
IT Af?
Board of Health, j Q Y M y , MA. ,
CERTIFICATE OF COMPLIANCE 0 6A
Description of Work: \ 0 Individual Component(s) ,Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned ( )
C
at
has been installed in accordan e with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _00
�" dated. Y'" Approved Design Flow -' r (gpd)
Installer
Designer: ev Inspector: Date: f
The issuance of thts permit sh not be construed as a, guara _ e that the system will function as designed.
No. Y FEE 94<... df 11
- COMMONWEALTH OF MASSACHUSETTS e� �f
Board of Health, 5'n r' n°l W t -'Nn
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to.; gConstruct(. ) Repair( ) Upgrade (,.A) Abandon( } an individual, sewage disposal system
at 0?� , �` `�' CA2c n't Q%%- as described in the application for
Disposal System Construction Permit No. CIL- dated -7-.)-- .7
Provided: Construction shall be completed within three years of the date of this permit. rAll local conditions lustbe.met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ,,�- Board of Health t '+