HomeMy WebLinkAboutApp-Permit-Compliance<< No. I `a —0 gS14 FEE r 00
COMMONWEALTH OF MASSACHUSETTS
Board of Health, )6 M.OVT4
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location f Y 61c,41
Owner's Name V r//,Y' h'zA&G. t F
Map/Parcel#
Address
Lot#
Telephone# 721/ 9"2)
Installer's Name , � �,g �,. <r
=` V K e
14/ K
Designer's Name
Address '�r,v, s - fG Cj L/"/m 1) u -0
Address
Telephone#
Telephone#
Type of Building -L'S" '��t1C —� ` Lot Size sq. ft.
Dwelling - No. of Bedrooms \ Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
gpd Calculated design flow
Number of sheets
Design flow provided gpd
Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
30-ThDESCRIPTION OF REPAIRS OR ALTERATIONS J9 JC Ce c �� i"c 130-
The
e undersigned agrees to install W, --v, descnbe vidual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not o pla a system i Certificate of Cgmplianc/as been issued by the Board of Health.
Signed Date �V d
Inspections
No.t i "I ku'_.loci 51-1 r ".a°' � E
4 2- COMMONWEALT14 Of MASSACHUSETT§,/,
Board of Health, M oapl 1114.
CERTIFICATE Of COMPLIANCE � J f � X L � � �. ✓>'"
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( Repai.;ed ( ), Upgraded ( )> Abandoned ( )
by:® o C. r+ Jea._
r
at
has been installed in accordar ce with the pro-7sions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No./ 6 / - ',5 , dated 7k,�!+ - '��x Approved. Design Flow ' (gpd)
Installer G f 0.", 4
Designer: Inspector: i/ f� Date: 4.s
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
,OGCOC�r, Of cc,.QC C G r,O o o 0'.i tJ 0 u 0 --),eco Co. )USC nC uc.(, CrJC Go 0000 (,t Q0:) 4 O 00 oq0 c 0001D 0, 1: 00r40irp'6&0-60
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No. k `� � � "% 4 L' 1..1 C Iv FEE
COMMONWEALTH Of MASSACHUSETTS
(� Board of Health, � D Ua , MA.
DISPOSAL SYSTLM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( (Rep Upgrade( Abandon( )an individual sewage disposal system
at 5-/47 &4,610vJ &ei
Disposal System Construction Permit No. 16 l /�-�5, dated 6
as described in the application for
Provided: Construction shall be completed within t4LQa-w� othe date of this permit., All local conditions must.be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date to /C'Board of Health
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