HomeMy WebLinkAboutApp-Permit-ComplianceNo. �b b W M—[ v — 000 1 1 ( FEE S 00
COMMONWEALTH Of MASSACHUSETTS
W �5
Board of Health,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
(� lication for a Permit to Construct( ) Repair( ) Upgrade( Abandon( -
�r
LlComplete System O Individual Components
ocation 2
Owner's Name
Map/Parcel# OS -4f r 23 0
Address Z
Lot#
Telephone# >6-- — — 7 C-2—
Installer's Name rn 0
Designer's Name
Address® L ] "� Z
11>� Address 726G 5
Telephone#
Telephone# - —
Type of Building Imo, EL7l�2 7I/t'
Dwelling - No. of Bedrooms
Other - Type of Building
No. of persons
Lot Size sq. ft.
Garbage grinder {
Showers ( ), Cafeteria.{ )
Other Fixtures
r
Design Flow (min. required) ,U gpd Calculated design flow Design flow provided 3 gpd
Plan: Date Re—L" At' %"Y 1 )L 17umber of sheets r Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
REPAIRS OR ALTERATIONS t
1 Ito __ __
Date of Evaluation
037
The undersign es to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth a e t not o lace the system in operation until a Certificate of ompli ice has been issued by the Board of Health.
Sign d Date
% e
Inspections iia 33�
No. bc,, H . �7'V 11- FEE S` . OO
COMMONWEALTH OF MASSACHUSETTS
a '
� f;+ a � (� Board o Health, �(ld4 `i�f�e 2136? 5
CERTIFICATE Of COMPLIANCE
Description of Wo z ❑ Individual Component(s) ❑ Complete System EE �
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ) , Repaired ( ), Upgraded! Abandoned( )'
by
at C-ofJCnQung LANE
has been installed in accordance with the provisions of 31.0 CMR 1.5.00 (Title 5) and the approved design plans/as-built plans relatibg to
application No. l -7-61-7 �, dated 1 � / `7 . Approved Design Flow 3S I (gpd) ,
Installer
Designer: #jL
Te:&C NP;"(rinspector:�"'Date: C
The issuance of this permit shall not be construed as a guarantee that the'system will function as designed.
No: s, (�C' `1 �` C�� /°/ %Yf • f L€i7J�/ i e;
COMMONWEALTH Of MASSACHUSETTS
FEE � J Q 0
z26 75
Board of Health, _�� —' AILA•
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair( ) Upgrade{Abandon( } an individual sewage disposal system
at
Disposal System Construction Permit No. 1'7--,&'%-7Y, dated
as described in. the application for
Provided: Construction shall be completed within three years of the date of this permiit`.. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date-ihb//Z Board of Health t ✓ c""