HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6WA�—4-786— FEE '55,00
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COMMONWEALTH 01' MASSAC14USETTS (Worm
Board of Health, VAJAMW rj�4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair(V1 _Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 8193
Owner's Name gt,4c, dgji +in _,5 hi f Jay S/'h
Map/Parcel# // L
Address I g—Te—
Lot#
Telephone#
Installer's Name I�F�T �� ov-r 49,= -Pic.
Designer's Name
Address ZY I.I�eJr.�Tn al �
Address
Telephone# S $'_ ,5-aq': Vo5if
Telephone#
Type of Building 1 S k i IT -S� Y
Dwelling - No. of Bedrooms 1] 4'ac"N'tit
Other -Type of Building No. of persons,
Other Fixtures
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided
Plait: Date Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &PI Ae—e O r�� 1" ��t'e l bod d l -r
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 an
further agrees to not to place the systjem� in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed 5i�7 ���'!� Date l^20`1.1
Inspections I Llk-`CL l7 ti iJ . itu' b t l lis
No. _� ""^i" 1' FEE
COMMONWEALT14 OF MASSACHUSETTS ck*t
Board ofHealtla, _ U �UT�ri , Am.
CERTIFICATE Of COMPLIANCE Z_
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Description of Work: individual Component(s) ❑ G
Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (K, Upgraded ( ), Abandoned ( )
by: lw—r-T &ur
at—4 7-3 k 2 IV
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. i dated C,,cam Approved Design Flow (gpd)
Installer C4, r ea�-
Designer: '""" Inspector: w G-- W-., Date: C G
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. (0�1- j (�-- FEE
Y
COMMONWFA
OF MASSACHUSETTS
Board of Health, SYSTEM- �� ��7iTi(���, MA. RM
DISPOSAL
TION
IT
Permission is hereby granted to; Construct( ) Repair(Ne Upgrade( ) Abandon( ) an individual sewage disposa syI stem
at �i x,3 eta e c s as described in the application for
Disposal System Construction Permit No. 17"R 6 s, dated G
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Poem 1255 Rev, 5/96 A.M. Sulkin Co. Charlestown, MA Date Ca L Board of Health /