HomeMy WebLinkAboutApp-Permit-Compliance' No. f b c -18 00 5 8 /,7-e> ' FEE 4 6Y 00
IV /1� 2, COMMONWEALTH OF MASSACHUSETTS
Board offlealth, YAR&D M, , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repairx Upgrade( ) Abandon O - O Complete System kindividual Components
Location 9,5 Y 1Aj(-- aK'-
Owner's Name 17C '�'(-A GAA -0 Z,(r-c-- (55,
Map/Parcel# -79/165
Address j„S V(xj
Lot#
Telephone#
Installer's Name C*P6%-j(-0&<- e-\Jm-- C
w Designer's Name WA
Address `
Address
Telephone# :5® .- wZ Z - 'Z%
Telephone#
Type of Building �65-1D0J —1(A, 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) 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�IliS i �4C lam- AJELV (4-(C) 0-80k w 1L4 K(s -
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r
Date b -Z -A0I
r
No. t Jt5 -C`1b r .e FEE 5.
C®I�'1 MONWEALT14 Of ASSACHUSETTS,, Y �
Board of Health, ON MA.
CERTIFICATE OF COMPLIANCE
4�Ztc
Description of Work:. X Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (�), Repaired (f, Upgraded( ), Abandoned
by: = a E���
has been installed 'n acc rdance with the rovisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.,tl a Approved Design Flow (gpd)
Installer -: l d
x r
Designer. _W Inspector; ' / Date: a= ` / k'
The issuance of this permit shall not be construed as a, guaranteiat the system will function as designed.
No. Pi C -(Ca •.00cl 8 FEE
l _ COMMONWEALTH Of MASSACHUSETTS
Board of Health, X11-� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission isheereby granted to; Construct( ) Repair(\) Upgrade( ) Abandon( ) an individual sewage disposal system
at_c Z5 \1116161M
116161M 90 �c Y48,4e 6-N as described in. the application for
Disposal System Construction Permit No. X'r dated �' a` ', X -
Provided: Construction shall be completed within three years of the date of this percal conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health