HomeMy WebLinkAboutApp-Permit-Compliance VOIDEDNo. --/ -7— 21 7Y:'
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17-61 NJ MO WEATer%SSACHUSET T'�, , l -
Board of Health, 0 ta:N , MA.
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairm/Upgrade( ) Abandon( ) - ❑ Complete SystemIndividual Components
Location J I y Lomq Periel b r,
Owner's Name tja I +,e—( j4b /14C_5
Map/Parcel# Z,� 4/,)
AdNss N CLI al;
Lot#
Tele one# 39,F_ 63 13
Installer's Name he_t-T R , r �, yam„
D igner's Name
Address ZCf b o e6lem 40 X01
ddress
Telephone# So?. O _ 67
Telephone#
Type of Building &66 f01e+'t T'A I Lot Size sq. ft.
Dwelling - No. of Bedrooms 1' Garbage grinder ( )
Other Type of Building, i" No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plait: Date N tuber of heets Revision Date
Title
Description of Sbil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date o'f,Evaluation
DESCRIPTION OF REPAIRS OR ALT RATIONS 1(1-�G l�'�� r r� M 'TD _rn ler
01 5ebht K
The undersigned agrees to the abo described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to_placethe tem ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r bt�t�.� NG Date
Inspections
No.��
/%®/
COMMONWEALTH OF MASSACHUSETTS FEE
Board of Health, Yagffi0 sm , MA. 6
CERTIFICAfi Of COMPLIANCE
Description of Work: OdIndividual Component(s) ❑ Complete System a
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (%I, Upgraded ( ), Abandoned ( )
by: ra �� B 'a4r'L0. 'rr'►G
at !I/ V ).,(R" Atnd b f
has been installed j'paccord ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.
LL/'' � dated Approved Design Flow (gpd)
Installer I�E1rT- ,J3 fjt,r �B • hL•
Designer:
Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
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No.1'''� '% 7 FEEell-
COMMON LTH OF MASSACHUSETTS
Board c f Health, �_, 0AJT* , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(VS Upgrade( ) Abandon( )an individual sewage disposal system
at L9V ,nary j ParwpDr� as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within tl+F@e-gets ofgt i date of this Kermit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ?Board of Health