HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE'
p}} Pe48 W7 6 COMMONWEALTH Of MASSACHUSETTS �� 1
Board of Health, �-rVl Oln , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct() Repair( Upgrade( Bandon(U Complete System ❑ Individual Components
Location ����
Y ri Owner's N(a�me V re &-r 7 1 G
Map/Parcel# i `
nl.fC"J
Address Dcj it 1 (� Cf 3
i
Lot# 1:2-11
Telephone# ( t rl' 9 b l -- ;L;-( o
Installer's Name `"f'
d _ . n j c Designer's Name e r-cw
/�
Address ,® Be X 153q'
RW Address 34f 9 QC)O i --C- a,& Utit� b W -'14A DJA
Telephone# 56ZE — 4
—o e 3 6 Telephone#SF Gt LCA
Type of Building 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) 1 d gpd Calculated design flow Design flow provided gpd
Plan: Date '�/ 9,g- 1 Number of sheets Revision Date
Title ^
Description of SOWS) d - SA 0 U M ICA /U
Soil Evaluator Form No. Name of Soil'Evaluator• voa 1413 Date of Evaluation o?
DESCRIPTION OF REPAIRS OR ALTERATIONS NS � �i 00 q QPL.
r Ca
The undersigned agrees to installthe above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to plac tem ' ration until a Certificate of Co pliance has been issued by the Board of Health.
Signed !J d Date 41 a31 13
FEE
COMMONWEALTH OF MASSACIIUSETT , ,.��
Board of Health, y iZ'M OLMi - MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 0 Individual Component(s) rnplete sygfm
The undersigned hereby certify that the Sewage Disposal System Constructed ( ), Repaired ( ), Upgraded O,Abandoned ( )`
by R UU to P- ` ~4 13 , oV t),)— Vzo
at. i0 (zTrteC1il�pe� L�
has been installed in ccordance with the provisions of 3 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.. % dated �/ �� -4VApproved Design Flow (gpd)
Installer"
Designer: 65C f rj') 0j; Inspector: Date: i
The issuance of this permit shall not be construed as a,guaranfee that the system will function as>designed.
No. -66912C =' ,.- 21 '� (tp \C� . jam FEE s �� U
I, f 7/ COMMONWEALTH Of MASSACHUSETTS
Board of Health,I�i� pJ-T 4
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at + ppe r- L ' j . as described in the application for
Disposal System Construction Permit No., dat df
Provided: Construction shall be completed within r, of the date of this per ni All locale tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date _--= =1 Board of Health
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