HomeMy WebLinkAboutApp-Permit-ComplianceNo.-bwpc-15-4gLt1 A6/J)c 4 -' 4" 4__/ FEE �X_0
/f-d-r3 COMMONWEALTH Of MASSAC14USETTS C" 104
LU i,
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
j A I
lication fora Permit to Construct(') Repair(,.) Upgrade( Abandon( - ❑Complete System O Individual Components
�r Vocation 3wS Le3m f i Owner's Name EsTA•m dl BAR RAQA MAP_T30C
Map/Parcel#
A
Address 8 SOO714 S'Z' S 714 &S-7Zvo MIN
Lot#
Telephone#
Installer'sName IOC r&VQ(,e Ager
Designer's Name
Address +.
Address
Telephone#
Telephone#
Type of Building L 510GOr /4 L_ Lot Size 101®1 q f sq. ft.
Dwelling- No. of Bedrooms Garbage grinder( )
Other-- Type of Building No. of persons Showers { ),Cafeteria ( ).
Other Fixtures
Design Flow (min. required) gpd Calculated, design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS S L A1C } H -1 C) [) ' %0y_ uicrtV _ Pu
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5-and
further agrees to no_tAQ placqthe system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date l - 9 19
Inspections
a No. FED r
c.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1 i� Ui , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage /Disposal System; Constructed ( ), Repaired X Upgraded ( ),Abandoned
at 2� 1k Lo &) & Twip �
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as.-built plans relating to
application No. �' clel " dated - ✓ _. Approved' Design Flow -""' (gpd)
Installer t C a -�
Designer: #.f jam- Inspector: ,r/IlDate:�Er'
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
g I', t t P��4✓ c 2"
j° FEE � Q
COMMONWEALT14 OF
Board of Health, �,Notam
DISPOSAL SYSTEM C®NSTRUCTI®NT PERMIT s
Permission is herebygranted to Construct( ) Repair(N) Upgrade( ) Abandon( ) an individual sewage disposal system
at (42 O O(z _20&)h ZiQ Q as described in the application for
Disposal System Construction Permit No. rV'4e- 73 , dated .
Provided: Construction shall be completed within L
s of e date of this pert it. All local conditions must be met.
" "% Board of Health Y
Form 1255 Rev. 5/96 A.M.'Sulkin Co. Charlestown, MA Date`, ` }'