HomeMy WebLinkAboutApp-Permit-ComplianceNo. � G-� 8-03 I I t✓D '® d�553 FEE' CI
COMMONWEALTH OF MASSACHUSETTS dv 0 1ga7
Board of Health, i ARAq i oT , MA. �6, c,
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade^ Abandon( ) - 0 Complete System Wndividual Components
Location 26 4v-A-- % 0drz&Ns 1-4V
Owner's Name �1(.-L- ✓4.'�/�� '� ,L.�. -.
Map/Parcel# j
Address �'✓)�1 L
Lot#
Telephone#
Installer's Name y; f�'_/�N'° &_eAV1 7L& LCC
Designer's Name ��+�}
Address M E'l-1 k, - / "� tl t .�,ry/G, .� i C r�
Address ? 0 iYfi 1 b` ) .1WV (_S
Telephone# g-J 4Z% ����
Telephone# 46 4 b
Type of Building j Lot Size Q' 4 f A-C sq ft
Dwelling - No. of Bedrooms 4- Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ) , �Cafa.
Other Fixtures /
Design Flow (min. required) 4oc0 gpd Calculated design flow Design flow provided' pd
Plant Date %I2nI1$ Number of sheets 1 Revision Date
Title Y it C��Jf�P 5�7e D�LC-Z uP/�iCaN 7 i�I�IN
Description of Soil(s) Soil Evaluator Form No. Name of.Soil Evaluator Y �)CQ/tttL I Date of Evaluation 3 I I4 /' Op
DESCRIPTION OF REPAIRS OR ALTERATIONS l31W 4 S -1-S J f (3 Z) Q U) C be L�
The undersigned agrees to inst4 the ve cr'bed Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o plac a sy item in o ration until,a Certificate oWCo plaar has been issued by the Board of Health.
Signed rDate
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No.te'�
COMMONWEALTH ILTH OF MASSACHUSETTS "I"
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Board of Health, MA. x1,k
CERTIFICATE OF COMPLIANCE 1 a,
Description of Work:; DAdividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed( ), Repaired ( ), UpgradedAbandoned ( )
by: ✓ <' n✓ (r` C.a U/) '' V 4 .)AtJ SeeaWlA O 1 Cif S' #i Q T"_CW
at
has been installed ii accordance with theprovision,,;of.�310 CMR 15.00 (Title 5) an4d he ;roved design plans/as-built plans relating to
application No. , dated./ �� / . Approved Design Flow v(gpd)
Installer 47
J
Date:
Designer. p t;� Ins' ector: _
The issuance of this; permit shall not be construed as a gu- tee that the system will function as designed.
— — - -= -
No. ` �� f �f`tt tq �(� SPEe AV__MAN) COO s 1Z, FEE, -mod-
� > 4 COMMONWEALT14 Of MASSACHUSETTS ck N 2.r�
Board of Health, 0�"(1-; , MA.
DISPOSAL S1 _M CONSTRUCTION PERMIT
Permission is hereby granted to;; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at /�l.•r��' �i:);f',_,;
I- q,-
Disposal System Construction Permit No.
r
as described in the application for
Provided: Construction shall be completed within tl�r,f he date of this per n' All local conditions must be met.
Form 1255 Rev. 5/96 A.M. S Ik n co. Charlestown, MA Date ILLr SBoard 9fHealth