HomeMy WebLinkAboutApp-Permit-ComplianceNo. bokVC46-0071
Board ofHealth, Y&/Z.MCm'4_ _ MA.
FEE
dwO ( 5-&
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) - ❑ Complete System 1 vidual Components.
Location a H , e N RoAb
Owner's Name -TOO MA-S lim-
Map/Parcel# S
Address Zoo
Lot#
Telephone#
Installer's Name
Designer's Name TC
Address 572,
Address 'at-as�i C✓
Telephone# o - q-77 -Vf---'Z7
Telephone# 585i_ -7 3 . �3'�
Type of Building PCs C �%���1��'� Lot Size 15, 13a+ sq. ft.
Dwelling - No. of Bedrooms 7 Garbage grinder {
Other - Type of Building No. of persons Showers( ), Cafeteria (
Other Fixtures
Design Flow (min, required) �J3 ® gpd Calculated design flow Design flow provided 34cl gpd
Plan: Date i ",;L3 - ac) Nu
/mber of sheets Revision Date
Title aL HA: 3 Es �V 0 Kp ?Q> YARkQ07H
Description of Soils) AVED C-OAASE: sC<--,-h �gWC
f 5EE p4x-o
Soil Evaluator Form No. Name of Soil Evaluator 14, '014gELj 7�_ Date of Evaluation -% " � � - Aa1
DESCRIPTION OF REPAIRS OR ALTERATIONS 06C Gy-1�tIV &1 11000
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(a) 5Uc) C�x4lW-. Lo Zkxcbu4A cdailgaw.5
t1.f �� '� �•��r o� i�r�{� 5' ��Ciu ua 1 x1 �-
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 o lace the system in operation until a Certificate of Compliance has been issued by the Board of Health..
Signed Date
Inspections
No. C►17i 1 COMMONWEALTH
ONH F SS CHUSETTS A--5 iV6}} i FEE .' ��.� f.�✓i/j
Board of Health, - A Y1� 6 C , MA. d 4bVtN
AT F COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System �
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), UpgradedAbandonedrn3O
by: Q.b 71 f
at !'
has been installed in accordan e with the provisions 31.0 CMR 15.00 (Title 5) and the p oved design plans/as-built plans relating to
application No. -f s1 , dated ""'r' �I Approved Design Flow'-- 01 (gpd)
Installer 1
Designer: Z3-C- JU6--/"R9diRJ Z jg Inspector: 6441 Dater
The issuance of this permit shall not be construed as a guarantee that th syst m willfunction as designed.
No. la - - _ FEE; t�
-74 COMMONWEALTH Of MASSACHUSETTS
Board of Health, VAAm a ar& , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(,K) Upgrade / Abandon( ) an individual; sewage disposal system
atas described in. the application for.
Disposal System Construction Permit No. -f9-41
dated F
Provided: Construction shall be completed within t4rr4 o-i5the date of this pert it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M.;Sulkin Co. Charlestown, MA Date -�3 As Board of Health