HomeMy WebLinkAboutApp-Permit-ComplianceNo. O H UC-Ir1'2� 13a -Fe -49-0(35 Z7 J FEE i 66� Ob
COMMONWEALTH Of MASSACHIIUSETTS,,,� Ll
Board of llealth, Ymmo urw MA. r
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION RRMIT/
Application for a Permit to Construct( ) Repair( .) Upgrade�.4`Abandon( ) ❑ Complete System udividual Components
Location
Owner's Name EA. U Lfij119114 CIL"
Map/Parcel#
Address Z Q�,KUp
Lot#
Telephone#
Installer's Name
Designer's,Name .
Address t ?
,
Address
Telephone#
''l ''l �$'�`�
Telephone# S73 Z
Type of Building MU 1"6 'PIWV v t�i Lot Size I I I VVO t- sq. ft,
Dwelling - No. of Bedrooms 9 Garbage grinder
Other - Type of Building, No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) -7 -70 gpd Calculated design flow '7710 Design flow provided % - -7 gpd
Plan: Date Number of sheets Revision Date
Title 4tJ
Description of Soil(s)
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS A;WD '1500 G ✓Li d-12 rTL�YYI�- t W y
L,%o G&A 132? i`U -0 — 3 24 V-)4 ^4 n_ Pf*, c� '73 -fir
�_AaJ— rUh-c 30 315'�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire =0t xhe system in operation until a Certificate of Compliancehasbeen issued by the Board of Health.
Signed Date
E
Inspections
No. FFE
bc COMMONWEALTH Of M ASSAC14US ETTS
Board of Health, 10 0 D4 , MA.
CERTIFICATE OF COMPLIANCE
Description of Work:. Cs 46dividual Component(s), ❑Complete System
The un�l)ersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepaiS ed ( ), Upgraded Abandoned
at _P'Ari-Vt,
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. /q- " dated �� " Approved Design Flow _(gpd)
Installer c, Ue. 6 l{ I
Designer: � '� C 0, Inspector:,�'ar��/1�® Date: �_Z Z -
The issuance of this permit shall not be construed as a guarafPfee that the system will function as designed.
No. tilt f l C° iy ,S �� Imo'l u"tC.. t . t.� r FEE
f
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, YZKM Q Jn_, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgra46�� Abandon ( ) an individual sewage disposal system
at as described in the application for
C
Disposal System Construction Permit No. dated _7-�/
Provided: Construction shall be completed withima_u"XZ_!�Ofthe date of this ,permit. All cal conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date s - oard of Health �'