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Home My WebLink AboutApp-Permit-ComplianceNo. �\'O T Z__ a_ C)o 10 � (0 FEE c 0 Q, 0" c -1? -02-23'- COMMONWEALTH OF M SSAC14USETTS �OD63 �2 Board of Health, '� Al A CATION FOR S SYSTEM P® AI. DI CONSTRUCTI®N PERMIT I Application for a Per it to Construct( ) Repair( ) Upgrade*- OrAbandonO - Q'Complete System ❑ Individual Components Location SeA V Owner's Name 3 6t% N kt. J\j AN Map/Parcel# Address U grmr,-A- Pii Acw C".), UJX410, IIiY Lot# Telephone#� Installer's Name ��- 5- $ Designer's Name 21 ASS Iv e (- -W �. e, Address P-6) Address6 3 N)S Telephone# -5 Oy� ^ ©s 50 Telephone#�- r Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Lot Size_ sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (mine. required) L gpd Calculated design flow_ Design flow provided gpd Plan: Date Z� % �ji�'�i Number of sheets Revision Date Title Description of Soils) t Soil Evaluator Form No. Name of Soil DESCRIPTION OF REPAIRS OR ALTERATIONS "7 r i.l n nJ d) m �'1vX%5 t3 _" Date of Evaluation ChD t;rat_. -rAwK _ ii-Zc, ?, ,/A to/ 1? The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to pla a the gtem in operation until a Certificate of Co plian a has been issued by the Board of Health. Sined W.,_6 Date Inspections ►b1? k 1-7 ave 15 5 �te'� C�22.p r12Q.f" No. Ott LV 1? FEES "7_ COM MON LTII Of MASS. USETTTS 3Z2- Board of Health,OII�J CERTIFICATJ OF COMPLIANCE Description of Work: ❑ Individual Component(s) O-C,mplete System The undersigned hereby cjrtif-y that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded , Abandoned ( ) by; 1� O S ' 1 y at r,� l P_t1(2sLr�V� has been installed in accgrdan with the ot'sto s of 340 CMR 15.00 (Title 5) and a oved design plans/as-built plans relating to application No. 1 7 �" 5" � dated � /' Approved Design Flow (gpd) Installer k) n hp, r--, %i (\U IL t' n C- 0-(2 I S 17)1 H1:_ y2- Q OI -- � p Designer: R,o&Q1 U'C spector:�( Date: A91131z The issuance of this permit shall not be construed as a guarantee that the system will function as designed. _;.)J.]u� 0 -)o Ji. JJJO 'O 0 00 00 0 .'Ll ll �.O01,00 JJO 00 CC''10000 "'0C, 0300 OJ:)OU O 000000.000 O JOO: J('i ODU C 000000000.000000 O 000100000 JC 0000000000 02,9 No. �it��' ( _ -0616-ilT b, 0,��_ t CJ. i,jc FEE - T -� � COMMONWEALTH OF MASSAC14USETTS Board of Health, �4VM 0 Qn4 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; rConstruct( ) Repair( ) Upgrade) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No./ dated P` " � � ! -7 C Provided: Construction shall be completed within-xhi �rs-� the date of this permit. ,All l6oal condition s be met. .>Form 1255 / M. Rev. 5/96 A.M. Sulkin Co. Charlestown, MA ,o Date J Board of Health '