HomeMy WebLinkAboutApp-Permit-ComplianceNo." 8o 40--t/ <51q�G 7&- k(k FEE' c
COMMONWEALTH OF MASSAC14USETTS GW(2,-77
Board of Health, � GV1, 0 01� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( - ❑ Complete System Yindividual Components
Location
41 ik-P P (n ()*L- R
Owner's Name 'JAJJG It491;S5 "
Map/Parcel#
Address 141 C. PC Cil1
Lot#
Telephone#
Installer's Name p�WtIJE � �-- R.B�
Designer's Name A
Address 153
(.gyp t -,`7.
Address
Telephone#
509_47 7_ '1 1
Telephone#
Type of Building E5 IDEOT Lot Size sq. ft.
Dwelling- No. of Bedrooms Garbage grinder { )
Other - Type of Building No. of persons Showers ( ),'Cafeteria
Oilier Fixtures
Design Flow (min. required)
Plan: Date
Title
Description ofSoil (s)
Soil Evaluator Form No.
gpd Calculated design flow Design flow provided gpd
Numberof sheets Revision Date
Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS =IS5JVj"►l1 EIej ig - t o I,500 G*1.GYt.i 6,6PY tG 'tA-*&)K
lJ) t ,& 05!�x-s A& " = t j sm*=LL m-Ew ' -a a w c rA (Z Asa. 1S g4-b
The undersigned agrees to install the above described IndividualSewage' Disposal System in accordance with the provisions of TITLE 5 and
further agree to no place a system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed Date (b j 0-O t S
Inspections
CZ?_ FEE C1.
No. ) C _-[g -6 Z�-�
j - COM40NWEALTII Of ASSAC14USETTS AS P)4 C. .-f 2 7 -7
Board of Health, �IA-Q MIS_, MA. 01���
CERTIFICATE OF COMPLIANCE
Description of Work:. Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (,_Upgraded ( ),Abandoned ( )
by: L-LO10t.�REW W-141+4 U:D QAPt=.J
has been installed in accord• nce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. , dated /49r -2'`('f Approved Design Flow (gpd)
Installer f-� Mt-cec-AR R t G. T C e'
Designer: _�� Inspector: . x2d —,2 A ,�:,s .^ ,oV Date: 1
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. -`-�� V�" c� C l .t tC (� i�` a�...f FEE, i 0-V
6 COMMONWEALTH OF MASSACHUSETTS a/ 12:77
Board of Health, Y40Mt OTM , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) RepairX) Upgrade ( ) Abandon ( ) an individual; sewage disposal system
at q C,,ram 7 ��F 7(1-WAd( �t' as described inthe application for
Disposal System Construction Permit No. -t< dated —
Provided: Construction shall be completed withint1j=kWrs474 date of this ri All local conditions must be`met.
Form'1255 Rev.5/96 A.M. Sulkin Co. Charlestown, MA Date ,"W .[ " 1 `Board of Health
L'