HomeMy WebLinkAboutApp-Permit-ComplianceNo. _�1{�/J 16 Icy —4 YL e ---, oO 3 0 � .FEE'
7v �} COMMONWEALTH OF MASSACHUSETTS jt* 5'uq
Board of Health, ��Dtf f 1� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
711 1� placation for a Permit to Construct( Repair( ) Upgrade/AbandonO - Complete System O Individual Components
Location c,
Owner's Name T 6 (� N A iZ1 XT L� CAvj
Map/Parcel# Al 24—>. &Led og
Address b 4 C ill.- LA/1i;
Lot# Ito 06
Telephone#
Installer's Name i� bJ1 i�2
Designer's Name P—OAXk0 '�S CEO% C
Address $ �/_ r:t rj -- 5 s l j_,,t% c 4,
Address P ®, i 2✓fl ,
Telephone# 5-D g - 3 Z
I Telephone* 5"0 ;b •- 1 Z $ - 9 '%O®
Type of Building �' - oul -Ti41 Lot Size I S ,. 3 O® sq. ft.
Dwelling - No. of Bedrooms 5Y # Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ),'Cafeteria ( ).
Other Fixtures
Design Flow (min. -equir d) 01,3 gpd Calculated designvv-Sr)" 1q Design flow provided S (013 gpd
Plan: Date o Number of sheets Revision Date JA V f14.
Title
Description of Soil(s) _
Soil Evaluator Form No.
Sira 5 A-V E W — Z4 .ate a VILU 15-% nO
Name of.Soil Evaluator 104 C4D�\1&C- Date of Evaluation 23
DESCRIPTION OF REPAIRS OR ALTERATIONS
I
�Al1(61) 4- p r' V-; 1-4 -to 1,5 a
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to not to place the system in operation until a Certificate of qompliahce has been issued by the Board of Health.
Signed Date i
Inspections
ion
No. ;� (0 l f '-�)t"� FE17 cio
i-
/ �— 9 CONIMONW LT14 Of MASSACHUSETTS �.. ��{ r
Board o Health, i 1 , MA.
f �'
CERTIFICATE Of COMPLIANCE
�
Description of Works 0 Individual Component(s) Q"Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded�Abandoned ( )
by: WE - 6e, -0 u j 10 t, i , [� P lQ t....-k3
at C.1)3
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has been installed in accor e with the provisions of 310 CMR 15.00 (Title 5) and the • - .roved design plans/as-built plans relating to
application No.,tz! , dated % j Approved Design Flow (gpd)
Installer V) .o �-A ,�J 1 izc. 1 tt...- . J?
Designer: fef.W1� ) 'I CA -01 CL.A- .- Inspector: � J (Y !.LZd' ! � �o Date:
The issuance of this permit shall not be construed as a, guaran�e at the system will function as designed.
No. _ �3 - i f )`i 5J �_ :ir C 1 E 't .(.Cif . � j U' j �jU f LTFEE_
COMMONWEALT14 Of MASSACHUSETTS 6W—# i i
Board of Health, NagI () , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No
Provided: Construction shall be complete
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MIA. Date
as described in theapplication.. for
dated -2-) 1
d withinkreA oth date of this permit. All
' local condi ' s must be ;met.
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" /'N Board of Health f Z
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