HomeMy WebLinkAboutApp-Permit-ComplianceNo. _W-x-1e'Gn3D
EEE'
Q --s3 OMIMONWEALTH Of MASSACHUSETTS at'�0
Board of ITealth, YQ r M C u +_L'� MA.
r
' ]LIGATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applicat n or a Permit to Construct(.) Repair(.) Upgrade4 Abandon( 'Complete --System 0 Individual Components
Location Lf1
Owner's Name
Map/Parcel#
Address
Lot# r j-C� (c Qjck�,-iC Ij.S
(n
Telephone#
Installer's Name Pi 1. voyw SEQw*---
t P ---n �-7
Designer's Name h � , Qs; ..0 p �►1(
Address �&4- bA
Address 1 C'Col t [Q( VZA
Telephone# S —(� —
S ��
Telephone# �C-� '7-f 5 f E_0}
Type of Building 2-eS l C&tl Lot Size of .STICK sq. ft.
Dwelling - No. of Bedrooms '2— ` 5 vl Garbage grinder {
Other - Type of Building _ r No. of persons Showers ( ) , Cafeteria { )
Other Fixtures /" i A
Design Flow (min. required) '�� Q gpd Calculated design flow _ Design flow provided gpd
Plan: Date % -41 F / 1-7 Number of sheets _ 3 Revision Date
Title
Desci
Soil Evaluator Form No,
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator Jr- l -P/ ItiIL 6n{aFR Date of Evaluation
The undersigned agrees to install the bye described Individual Sewage Disposal System in accordance with the :provisions -of TITLE 5 and
further agrees to not to place cyst " err ion until a Certificate of Compliance has been issued by the Board of Health.
Signed Date S 7
rw t i
Inspections /A `/ ? z—
t� s
�y
No. d t S �.. 4 C� � �1 �y, �c f,} E
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) g(Complete System
The u;�n�ders,,irg�ned hereby certif that the Sewage Disposal System;., Constructed ( ), Repaired ( ), Upgraded )<' Abandoned
11
Ll
has been iistailed�acr dP�
—T ��~�
ante with the 'ovisions o 3] 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No:dated /r. Approved Design Flow(gpd) „
Installer C... i/ -S vw w`. '�/, ��.
gn il�1 p, ✓✓C,�! 1 Date: 7
Designer: ='.6r1r. � n -24's �✓y (tU .n �At � Inspector:
The issuance of this permit shall not be construed as a gua6?nt e he system will function as designed.
_:_-_ :'' _.. ,_ -. >...�_ meg._,..,: r:. ___. r-. " �_.-- ., � ..,�- •' ._ f
.No. )�1�.Slt _' J C�a ) � 1bVc-)tllo. FEE! i
j COMMONWEALTH Of MASSACHUSETTS 4 1.
Board of Health, YGt �r lh cn., P" -t^ MA..
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an indiv=idual sewage disposal system
at
as described in. the application for
Disposal System Construction Permit No.
} '" � dated
C.
Provided: Construction on shall be completed within tlar�ear, h date of thispe 11 All local co , ns must be "met.
IV _kft
Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA
�1 Date / Oard Of Health (--,/ CIA
i9� r° r14! .:rt fault"'.' d