HomeMy WebLinkAboutApp-Permit-ComplianceNo. �1't�C""���iJ��Z (bLJ)TQ,_ 19- dd1�l(0 FEE55100
1pyee� C,4, Board of Health, ' Ca i' nl o u� AM. Y 6o(
APPLICATION FORDISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair(v)"'UpgradeO Abandon( - ❑ Complete System individual Components
Location i fi j 1-0
Owner's Name G iC
26
Map/Parcel# O 3 Q
Address
Lot#
Telephone#
Installer's Name �, '
S3 . i3 Ex 0-0,UC A I o,r�
Designer's Name
g
Address Tco.Sct-r orc c.
Address
Telephone# 0 (� S3
Telephone#
Type of Building Re.5; j1=j) d is Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) SSO gpd Calculated design flow
Plan: Date i 7-9 19C$ Number of sheets 0
Title
Description of Soil,(s)
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS Rc_-rnqu-_ r_-xzjrq
Design flow provided - ``25 gPd
Revision Date
Date of Evaluation
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 Certificate of Compliance has been issued by the Board of Health.
Signed &2&-t Date
--
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth, rr-, 0 c A MA.
CERTIFICATE Of COMPLIANCE ,eft l6
Description of Work: "dividual Component(s) 0 Complete System
<a bt
tv e-� t
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (vj`'Upgraded ( ), Abandoned (
by A, P) r-ACQOxnl� 0 A
at '"14 A Ltj
has been installed in accordan e with the rovisi ns o 10 CMR 15.00 (Title 5) and the; approved design plans/as bttilt plans relating to
application No.If, dated. Approved Design Flowgpd)
Installer S =� X « V I O ! `�K- ! L
Designer: Sr-o t zD Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system willfunction as designed.
No. `--��'2^
:a COMMONWEALTH Of MASS CHUSETTS
Board of lealth, MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
FEE, C55, 010
Permission is hereby granted to; Construct( ) Repair(, Upgrade( ) Abandon( ) an individual sewage disposal system
at 9;I e as described in the application for
Disposal System Construction Permit No.dated !`Y
Provided: Construction shall be completed withinlb="slo , t e date of this permit. All local conditi s must be met.
Date f 4, Board of Health
Form 1255 yRev. 5/96` A.M. S'ulkin Co. Charlestown, MA '" i ®/