HomeMy WebLinkAboutApp-Permit-ComplianceNo. o{� 77-0345 �~ o a 1 FEE
COMMONWEALTH OAF MASSAC14USETTS 5
Board of Health, Q , MA.
sell .ICATI®N FOR DISPOSAL SYSTEM CONS RUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) Complete System ❑ Individual Components
Location 457 aZP1WW1.,7*PX;Cr,0ZV?,5'
Owner's Name 11 1 CW
Map/Parcel# ���' S'9
Address q
Lot#
Telephone# �56�) � _ Q4?49
Installer's Name.� w amd (km L
Designer's NameAJ Jnt b9316W Lb�,
Address A�U�O-A -r
Address * VIS E
Telephone# 6�- o
T Telephone# t5o _
Type of Building $Iflr-N'd7/.II_ DA65ktJ& Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other- Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (mina required) 550 gpd Calculated design flow, Design flow provided 5q qgpd
Plan: I
Date �I J��l°% Number of sheets Revision Date
Tidedijesaver deffAxhiposAL &M-9 ,IiTF aA9 Ag® fl&FILA
Description of.sbil (s) okr (9W SAAU)Y / AA sgJLT' /AA9 t SA 9b
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS A" d bd r A, 1866 6-ALZAAi —SWW� Pir 1V T dAS FSI Z h
KUU4 i1-,0,0 PrALad-lUk , bJ &- 3Mb9 &)c AXb IS &47V 99-n xS0�it�rr�
The under agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree not to p the s tem in operation until a Certificate o mil' nee has been issued by the Board of Health.
Signed L Date '�� I
No. 1 FEEi
OMMONWEALTH Of MMSACHUSETTS
Board of Health, yP, MC)NM3 , MA. `
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) PLComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandoned ( )
.W
has been installed in accordanith the rovisio sof 31 CMR 15.00 (Title 5) and t�� roved design plans/as-built plans relating to
application No. _17
ated Approved Design Flow "�(gpd)
Installer
Designer: 1 to 16 fl% Inspector: 4Aitp4f-t,•, _Date: .d27
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
i-�i7 �. r
No. > �.- — t��-c� _t�- �•.-i la'a FEE�,fi�J
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COMMONWEALTH OF MASSACHUSETTS car � �ac�Mi
Board (f Health, �A&8QMJI , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (X) Abandon( ) an individual sewage disposal system
at (n U,U t r i &I S)7. (1 as described in the application for
Disposal System Construction Permit No, dated �p�
Provided: Construction shall be completed within thr.._,. r date of this permit. el local conditions must be met.
Form 1255'Rev: 5/96 A.M. Sulkin Co. Charlestown, Ma Date l t' Board of Health