HomeMy WebLinkAboutApp-Permit-ComplianceNo. �o {'iD C -C !—[55�
COMMONWEALTH OF MASSACHUSETTS
Board of Health. 'VV --%1'1®(, , NM
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct()Re air() Upgrade �Abandon om Tete System 0 Individual Components
Location oZ
Owner's Name ZkCVIV�LN
Map/Parcel#
Address
Lot#
Telephone# t ass— 6(sc)
Installer's Name v
Designer's Name gCb,
Address 025 CqQJ&T6 0_
Address 15S C-140 9N)AZV- _
Telephone#'zF1
Telephone# ply — 31, 14 _ o
Type of Building 'PsSt�+•��'ll � Lot Size q 4 00 sq. ft.
Dwelling - No. of Bedrooms y Garbage grinder
Other - Type of Building No. of persons Showers O, Cafeteria
Other Fixtures .
Design Flow (min, required) �� gpd Calculated design flow Design flow provided_ gpd
Plan Date � l 1 t-1 15w ? Number of sheets Revision Date
Titley
Description of S'oil(s) eic� SP1 d
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS k "S-nZ�11
PC -w 'Sc o e-
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n to pl. ie system in operation until a Certificate of Com fiance has been issued by the Board of Health.
Signed Date tiZ 2
No, r +i it 0 ;1. "i� ' 559 FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YL1?Mo(,qA , MA.
!CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) OComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (V,Upgraded (ti. Abandoned O'
by:
has been installedi accordance with the provisions o 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No:, �..- , datedIT . Approved Design Flow(gpd)
Installer a c r ti- \ J. ( a -s i e%j
Designer: 1;F(,.(, — TC 04--, Inspector: Date:
The issuance of this permit shall not be construed as a guar ---tee that the system will function as designed.
33
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No. —.E% 0 1 t" l�% "� i i_ ii y°�l r /� J 1� �: l —! s/ F� . 4 d 12 , FEE 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, V, ACA160 t1TIA� , MA.
DISPOSAL SYSTEM C®NSTRUCTIONT PERMIT
Permission is hereby granted to; Construct( ) Repair( v3 Upgrade (Abandon( ) an individual; sewage disposal system
> as described in the application for
i
Disposal System Construction Permit No. `C 1 dated
Provided: Construction shall be completed within+kwoe.yyo*rs of he date of this permit. All local Gond' 'ons must be met.
,
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date / Board of Health
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