HomeMy WebLinkAboutApp-Permit-ComplianceNo. �Tl C ^ ✓ [3 TQ,— ® () �y % FEE & v `�
COMMONWEALM Of MASS C14USETTS
Board o eaCAW''�t%u
f Health, MA. �
APPLICATION FOR DISPOSAL SYSTLNI C®N TI�UCTI�N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon() - Complete System ❑ Individual Components
Location 90 &AA0bV1&W OR I %!,e
Owner's Name 055-
M Ee-L�
Map/Parcel# 91/120
Address gee PARSUF-
<2A
Lot#
Telephone#
Installer's Name C APE (Sec',Designer's
Name TC
Address 153 C d,.t - M i G�
AddressapgsLf ( d7
Telephone# a- — —:FS—:FST7
I Telephone# -
3 — (0 -'1
/-e
Type of Building Pes t l,4 -L- Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 D gpd Calculated design flow Design flow provided 33 q-9. 4 gpd
Plan: Date 'LOt -1 Number of sheets ( Revision Date
Title �-A L J6 0L.Y-71-1
Description of Soil(s) C -01l u /fit 6i C a
Soil Evaluator Form No. Name of Soil Evaluator M �PCiU c= -X; *a- - Date of Evaluation 9 '31 '' 209
7
DESCRIPTION OF REPAIRS OR ALTERATIONS YiUSZ LSC.. ;2500
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ` Date f O" 30 XO (I
Inspections
r C®�l MON LT14 Of SSACI ETTS
Board of Health, ,4;ZW W n4 , MA. -
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
` The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: D94.) [1,91 EachIEW-RA KEK Z iC644kb 64PG .j
at S — A1V�? J�"4,i 1MJYEE 5aQ-6E
has been installed in accordance with the provisi s of _UO CMR 15.00 (Title 5)and tap roved design plans/as-built plans relating to
application No. % — 7, dated �i r% Approved Design Flow?-4-P.(gPd)
.-1
Installer CAPS rbC5'
Designer ZrC E(l1G-, fbjt�VJ6. `lam --JIL4- Inspector:// Date: �•�� 2 %:1
The issuance of this permit shall not be construed as a gua�ntee that the system will function as designed.
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FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, VAW4,rx-ai-4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 2Q ��Lsi! `/���� L J �lkC as described in the application for
Disposal System Construction Permit No. L7 --J-'1- I, datedf
i '
t S
Provided: Construction shall be completed withiruhzao ►� of the date of this permit. ) ocal conditipns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Coo.. Charlestown, MA Date oard of Health f
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