HomeMy WebLinkAboutApp-Permit-ComplianceFEE10, Qd
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YPA�TTIIA , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT.
Application for Permit to Construct Repair( ) Upgrade( ) Abandon( ) 5 Complete System ❑ Individual Components
Location 1,�17
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Owner's NameG,��sS®r„t fit C
Map/Parcel#
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Address V/,Pra, (�/s,�-ee j�- f o�
Lot#
Telephone# 79-1
Installer's Name
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Designer's Name s�nn et eti 11
Address �`%
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Address J SAC enn0 AXA
Telephone#
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Telephone# Q �� ;� /,EoZG
Type of Building ��Sf%� � ��`�/ Lot Size �e- Sgv'2, sq. ft.
Dwelling - No. of Bedrooms FT Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow 310
Plan: Date o44<01- a-' /7 Number of sheets�+�
Title
Description of Soils) _
Soil Evaluator Form No.
Design flow provided 3,6 gpd
Revision Date T�"e-7 / 7
A'' c/
v
Name of Soil Evaluator 7J' Ac-r✓6,2 h 1, n Date of Evaluation 's fy 7
DESCRIPTION OF REPAIRS OR ALTERATIONS C�Cih ��/re % ✓)�✓ �Cvt racj.�
e'al -
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 Yas been issued by the Board of Health.
Signed �c� Date Jr-Al-1 17
Inspections
No. I'�.�1)F-I C,<' � � ,,,�i, '� .. FEE .�//f�.
C®MMONW LTH OF MASSACH US ETT�
Board of Health, —iA-0m1) k , IVIA. N
CERTIFICATE OF COMPLIANCL
Description of Work: ❑ Individual Component(s) omplete System The unde>signed herebyzertify that'the Sewage Disposal System; Constructed.Repaired (.), Upgraded (N) Abandoned ( )
at �4-I�.)
haas been installed in with the i�osvisic ns o 10 CMR 15.00 (Title 5) and the. approved design plans/as-built plans relating to
application No. dated C� Approved Design Flow Z (gpd)
Installer z
Designer: P,\jpjraj"L..T74])CS t6 A Inspector: .i�e ' Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. r) "i c 6 017 7 I C Q I? �Ft `- IM i• V ` T ffzm C� _5 FEE il 16. tom)
4 COMMONW Ck;�-- qs' /1-3
Board of Health, \� n , MA.
DISPOSAL SYSTEM C®NSTRUCTI®NT PERMIT
Permission is hereby granted to; Construct Repair( ) Upgrade( ) Abandon( ) an indiNridual;sewage disposal system
at
as described in. the application for
Disposal System Construction Permit No. i ' - dated S
Provided: Construction shall be completed withi - s o lie date of this perm' .All local conditions must be met.
Form 1255 Rev. 5/96 A.M.,Sulkin Co. Charlestown, MA Date l- / �.�` Board of Health O