HomeMy WebLinkAboutApp-Permit-ComplianceR — 1 ��`� �FEE
No.
a. T
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ICL1r ffVXJ-' , MA.
PPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair(') Upgrade(I)-<andonO _-complete System ❑ Individual Components
Location Carr iaQXy&rftXVS
��y- Owner's Name S d 6191VV
Map/Parcel# �x
Address /g , �. f - • �� �j G
Lot# a9 -8
Telephone#
Installer's Name r Ld& 1
1 1C_ Designer's Name��
Address qs � r 01�
"lk o. Addressf-
Telef 79
Telephone#,1.
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required) 13 aC> gpd Calculated design flow
Plan: Date,TUj'W _jnt, aot3 Number of sheets
Title t tit=3�S&trrlac
Description of Soils) -,�
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size °� ��� sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided 1332. gpd
Revision Date Juk�j Z;6;'- ap l s
Date of Evaluation
The undersigned agrees to ' t the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to ttto ac the system in operation until a Certificate of C plian a has been issued by the Board of Health.
Signed Date
�_ �G_ �U_ SGS (— aue✓fie (r —OCA
Inspections
Comm
ONWEALT14 OF MASSACIRA�T'.,
�Vy14
c ��
Board of Health, MA.
COMPLIANCE
CERTIFICATE
Description of Work; ❑ Individual Component(s) Z Complete System
The under 'gned hereby c rtify that the ewage gisposal 'ystem; Constructed( ),Repaired( ),Upgraded (Abandoned ( }
by:, d �'
at rl�
has been installed
application 3o. A
Installer
Designer:
The issuance of th
No.-�
i- L0.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade Abandon( ) an individual sewage disposal system
as, described in the application for
Disposal System Construction Permit dated
Provided: Construction shall be completed within �'of the date of this permit. All local conditk6ps must be met.
Form 1255 Rev. 5/96 R.M. Sull�n ate Co; Charlestown, MA '� Board of Health