HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE $6v,"
6L-bTI2 11- 00073Y
17 77- COMMONWEALTH OF MASSACHUSETTS
YA�'�"�L'TH "EALTEFT.
Board of Health, ii ,
APPLICATION FOP, DISPOSA -MMLCT�ONUION PERMIT
Application for a Permit to Construct( ) Repail/111"Upgrade( ) Abandon( ) - ❑ Complete System Xdividual Components
Location
Owner's Name r—
Map/Parcel#C46, 57
Address
Lot#
Telephone# d`"g OF dT' ?fes X77 9
Installer's Name �/ f� �' `d ��"G,/
Designer's Name �° �� �,✓ ./;
Address �� �"J� /,�'y�
Address
Telephone# d—O 40 7
Telephone#
Type of Building ��iy �/���"�f�/� d Lot Size44 e / sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 ® gpd Calculated design flow_ Design flow provided gpd
Plan: Date Number of sheets .�' Revision Date
Title
Description of Soil(s) C,J'O/G" .e'o
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS J 44:0'e 4004"e*e
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree of to DlaceAbe system in operation until a Certificate, of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No. ✓N�"'V --Alf FEE
COMMONWEALTH Of MASSAC14USETTS.1 ZIA
Board of Health, sem. 'G�/%l4�;r / , MA.
CERTIFICATE Of COMPLIANCE 1-7
Description
Description of Work: I'7 Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded ( ), Abandoned O
by:� da% cd"'''c��y, J�Gcd".J�'"%-✓G cI` 1/C; }
has been installed in accordance with the roviisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ! �` �a dated W. �d 7 Approved Design Flow
Installer 7 - OexrG "- �n<
Designer:— Inspector: � Date:
The issuance of this permit shall not be construed as a guaranee that the system will function as designed.
No. C j�* (-'- u
COMMONWEALTH OF MASSACHUSETTS
Board of Health,�42G6i%yl �/ %%� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( )
at <!?, G- ...f 1, -.dr
FEE �1 0
44 y(eq
I
Repair(10f,**'Upgrade( ) Abandon( ) an individual sewage disposal system
as described: in the application for
Disposal System Construction Permit No.1�, dated_' /7
Provided: Construction shall be completed within th*hof the date of this per i All local conditions must be met.
'1�, �� �
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date Board of Health
i./