HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1 Cf �/ FEE'
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COIMMONWEALT14 OF MASSAC14USETTS CkOS56
Board of Health, Y Al "krr)+ , MA. ^ `y
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION
,PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(�bandonO ❑ Complete System Individual Components
Location16 6 S,TQ.
Owner's Name RQniA10 i 05:k>!
Map/Parcel# 9g
Address J � cr T
e�
Lot# �p�j
Telephone# I
Installer's Name (.Nt i+Eii' �
Designer's Name 11,C J&J&10q— -V"
®
Address 153 0,0 l
Address
Telephone#'50!9-q-77—'2S1]
Telephone# -
Type of Building (DWT i AL, Lot Size 16 19 00 # sq. ft.
Dwelling- No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers (J , Cafeteria ( )
Other Fixtures
Design Flow (min, required) gpd Calculated design flow Design flow provided 3 9 + gpd
Plan: Date 5,- 0 ao 119 Number of sheets L Revision Date
Title 10 O ffR.A1 P4) JQV-riA Y«kKr-ZWTW
Description of Soils) _ — • - .9% "' t/ �•., — ��1� 97 5 V% % t�-� n. 't. D
Soil Evaluator Form No
Name of Soil Evaluator M �?-t i'1� -MJ ' -Date of Evaluation
DESCRIPTION OF REPAIRS OItALTERATIONS U66 L�(js`T1 JV 150-0 (Z.*LL-Q&)
Mssk) 14-1 y 0-a& � ! :500 Q W - l o L,6 44106-- <A&AgQ� wc-t�Vor- &6AgGAnll�- 15
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the. Board of Health..
Signed C -1c � Date 4,-/ 0 � �
,
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COMMONWEALT14®F MASSAC14USETTS
- Board of Healtli,®�ST'"1+ , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: .Ll Individual Component(s) ❑; Complete System � 4 ,1 k4teo
The undersigned hereby certify that the Sewage Disposal System; Constructed ( )> Repaired ( ), Upgraded ,,.-j^Abandoned ( )
at Ili GGRVA2b Sr SOQ AAOV Q
has been installed i accordance with the provisions of 10 CMR 15.00 (Title 5) and the pproved design plans/as built plans relating to
application No. f - rC-41, dated 7 Approved Des*rk Flow gpd)
Installer - E _ -
Designer: aC ��i y1�d� b"" leb TUr, Inspector: J64--/Vw _ Dater
The issuance of this permit shall not be .construed as a guar tee that the system will function as designed.
l e' COMMONWEALTH Of MASSACHUSETTS
Board of Health, 1 6 jxa� , MA-
DISPOSAL
A.DISPOS L SYSTEM CONSTRUCTION PERMIT
FEE 0
:-I oso
Permission is hereby granted to; Construct( ) Repair( ) Upgrade bandon ( ) an individual, sewage disposal system
at Gepnvuoh °` ' , VAX as described in. the application for
Disposal System Construction Permit No. '/ , dated-r-::� .
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date?_ Board of Health f rc' �-