HomeMy WebLinkAboutApp-Permit-Compliance�No. SOj%--'4�79-..1 ZS' �/),V-- G,�J
A -� V sFEE ��
C®ONLTH
OF MASSACHUSETTS ??7
Board of Health, Y119 -MO UW_, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location
9 0,,,y(1 C
Owner's Name N 4. t1 ryM W01 A 44 t_
Map/Parcel#
1 -7W11 ->L$' 3e s/
Address rr--
Lot#
Telephone# -7 1- J 1 6 a G S 2 Nl A C le Z6
Installer's Name
Designer's Name T. DI 2Gmeete4—f'
AddressO
o Oneou en p .021.0Address
3rloA.L,s n1,4. OZ e. 3�
Telephone# 5,99
.L771y
Telephone# s0&. gq6- 66O/
Type of Building Ro ft 1 #3 ea, a-tc-1 Lot Size
Dwelling - No. of Bedrooms
Other -Type of Building At9 ^ `k K. No. of persons
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS jZe 0 ta[ -[L D t5 6 rA
AU!n Aa , -L ct!c Au czr W 14 �s i Gni
gpd
The undersigned a7gree o ins;the
the ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees place eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date�h
Inspections Y.Acef &3
No. DC''�-0�2-5 FEE 0 S�• 0()
COMMONWEALTH Of MASSACHUSETTS 4-4 -7-77
Board of Health, YA12M 0 UTW ; MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired, Upgraded( ),Abandoned( )
by: A j K I _f -e-AS T C()MS-Ml L) C l�d,-J
at I "7 L, 5 u v --a t_ A\YL
has been installed in accordarIce with the_provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. / %- dated �' I� � 7 . Approved Design Flow (gpd)
Installer VUL C +
Designer: Inspector:; ' -! L / liL+ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. �C�� A-" -C 2. Noie_ }r E-A S f ` nIJ��Zt% G/V FEE S GV
COMMONWEALTH Of MASSACHUSETTS - 7
Board of Health, VAe-M 0 Qll k , AM.
DISK®SAI. SYSTEM][ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair Upgrade ( ) Abandon ( ) an individual sewage disposal system
at /-7(, SO U Il -i 5CYA AV / \ �as described in the application for
Disposal System Construction Permit No. / d� , dated 7
Provided: Construction shall be completed within th `- r�the date of this per ' : ,All Vocal c editions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date /_,/-! Board of Health
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