HomeMy WebLinkAboutApp-Permit-ComplianceNo. V�`��5-618b FEEW
COMMONW�ALTH Of MASSACHUSETTS 6&"-Zv
G�PCAVTION
Board of �Iealth, �>�1/� Di��}} MA.
A P FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade�AbandonO -'E] Complete System ❑ Individual Components.
Location 1vr�-x iii
Owner's Name r
t�'d3-rj Tf{
Map/Parcel# ISO
Address lot /J .
2 a t // % vl + 7 A I
Lot#
Telephone# sa&- OW
�V 0 rj � �o <�' a&-;-
Installer's Name �; �� ' cc-' V�—
Designer's Name
1 -77
Addresser !�'i�rl
Address
Li
Telephone# (pAin
Telephone# Svc S(d
r2Z-i"14",1.
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building
Other Fixtures
Design. Flow (min. required)
Plan: Date G
�-rZ.. . .1 Q'
Lot Size sq. ft.
Garbage grinder (
of persons Showers ( ), Cafeteria ( ).
9 gpd Calculated design flow Design flow provided __ gpd
Number of sheets Revision Date
Title
Description of Soil (s) SQt _
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS E -e
The undersigned agrees to inst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and
further agrees to not lace a sys min til a Certificate of Compliance
, has been issued by the Board of'Health.
Signed Date
es
Inspections
o-
al&c
J
�] FEE
COMMONWFALTH OF MASSACHUSETTS� z o z,o
Board of Health,V �A� M! , -
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) 006 inplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedd..�rA' iandoned ( )
by
< i ). r. ).
..r , t�C= _
at 4E "A iii ti's"`• �r'� pi,.etie :�f Yom% f- i ..� t'-...1 �''1 ly-, i
has been installed •n ac ord• ce with the provisions o 1.0 CMR 15.00'(Title 5) and th--e--ap��roved design plans/as-built plans relating to
application No. f ,dated Approved Design Flow Flow,
Installer ( vii l r r
" �.
Designer: c.y s )t tit e O >.pr. v r ( r' Inspector: // o (. 1 ys r` Date: ��v
The issuance of this permit shall not be .construed as a,guaran'tee that the system will function as designed.
No. _ .. i E� � .-(916! 5 4 t -t v %tC 3: > FEE e .` v � V -
-
COMMONWEALTH Of MASSACHUSETTS � • ��
Board"of Heahk A o 1 ml , MA.
DISPOSAL SYSTEM C®NSTRUCTI®NT, PERMIT
Permission is herebygranted to;, Construct( ) Repair( ) Upgrade{ Abandon( _;) an individual: sewage disposal system
" Cc t. � �p fc, ,. �� ^ Y � •� ' '1 r' as described in theapplication. for
Disposal System Construction Permit-�.. I dated
Provided: Construction shall be completed withirt4br&vim®®f e date of this permit.
-� All local conditions must met:.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date J Bp aril of Health
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