HomeMy WebLinkAboutApp-Permit-ComplianceNo. 604D C, ���c7& V1 9--18 4*g37 FEE t 515 S
COMMONWEALTH Of MASSACHUSETTS
Board of Health, `>iQed►1cr,/'1- m , MA f� J
r
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for a Permit to Construct( Repair( ) Upgradek Abandon( - ❑ Complete System P° ndivdual Components
Location '?7 "V -C 1 c W-4tsf-
Owner's Name "o -t- ei.� ( e1 ,
.&
Map/Parcel# 9 _2
Address Lk,�.L 12A V)�-tA- 'f"
Lot#
Telephone#
QZ6 7-3.
Installer's Name t?j 3 � CGV� � dti
Designer's Name VE,, i ����,. r
G It,`
Address--��c. '� c �
Address l Z (pj, C,r-Zas)-C:-Qw
Telephone# P, (52 4 y
Telephone# !g-ay—(4 77 _ 5- 3: t"3
&-z cx `iw
Type of Building e nS it �� 44
Lot Size sq. ft.
��+ r' 444 -�+�` ^ '� Garbage grinder(
Dwelling- No. of Bedrooms ��--•�+---•
Other.- Type of Building No. of persons Showers ( ) , Cafeteria ( ).
Other Fixtures rj fit -
Design Flow (min, required) gpd Calculated design flow I; Design flow provided
Plan: Date 5 )Zf- Number of sheets Z Revision Date
Title
Desc:
Soil 1
�A •f-- i m, 4 a f'1- "A
Date of Evaluation ✓171 1a
5E7 -Ijs y z
DESCRIPTION OF REPAIRS OR ALTERATIONS'
The der ed ees to' tall the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further a ee not to c e system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed � Date
Inspections
�t.
No. '1 (� ek� ' ig' Z- i as
COMMONWEALTH
(��T�}�� Q �( ��( {gyp MASSACHUSETTS
� ( T FEE
Board of Health, Y -'C C' fvt (10 MA.
CERTIFICATE Of COMPLIANCE s"
Description of Work; Individual Component(s) O Complete System.
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded �"rXibandoned ( }
by: 6-2 -k' 6 r -W'-5 t k�) (1[,? -A N3-3' .
has been installed ' i acc` d ce with the provisions of AO CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. l � / , dated `Z % Approved Design Flow =(gpd)
Installer SR C, Lax i^;u�°' 4
Designer: ��IIX(--SZ-It`- e.l ) Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.G�\�C t j `��'4'�✓L.l�q�{�� FEE `>,,
100
Board of Health, �a t- Y ► ey i-(,% , MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygranted to; Construct(. ) Repair( ) Upgrade(^j Abandon( ) an individual sewage disposal system
at -?74 �--C114 rlel WC110 �^ ' f� � t c` t b' as described in the application for
'r �.:
Disposal System Construction Permit No. kdated
Provided: Construction shall be completed within three years of the date of this peri i All local conpns mustbe met.
\1
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ' �` I/ V Board of Health