HomeMy WebLinkAboutApp-Permit-ComplianceC�-A -32-61 FEE' 1
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1�- / C®�!1 MON LTH Of SSACHUSETTS GO�I -7
4 � 1A, 01 Board of Health, 6-Y' Yn Q, a=O , MA.
PLICATION FOP, DISPOSAL SYSTLM CONSTRUCTION PERMIT
^A plication for a Permit to Construct(/ Repair( ) Upgrade( ) Abandon() lE(Complete System ❑ Individual Components
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ovation
Owner's Name
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t � v e`
Map/Parcel#
Address
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Telephone# ° a"j' 2_7
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Installer's Name 5 CDCo Y_cs�wr�N�
Designer's Name
Address `Z t r
Address�--
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Telephone# � vY ^ F1 - Z t I S^
I Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building No. of persons
Other Fixtures
Lot Size U sq. £t.
Garbage grinder { )
Showers (), Cafeteria ( )
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Design Flow (min, required) gPd Calcul_ated design flow Design flow provided FgPd
Plan: Date 12-1 Numbeof sheets Revision Date 3/2-7/11
Title —. i �"`� 3 tc�J .` !� Q U YV_ u a. �- iii l." t% r..
_ !� MA
Description of Soil(s)'. 1' 'J`''^ � � �'g_CV-k-f-
Soil Evaluator Form No. Name of Soil Evaluator ^''� Date of Evaluation
fit
DESCRIPTION OF REPAIRS OR ALTERATIONS I�/ A'
The: undersign grees to install thea vades' en
Individual Sewage Disposal System in accordance with the provisions of TITLE 5 andfurther agrees - of o place to inuntil a Certificate of Compliance has been issued by the. Board of health.
Signed Date
A A
Inspections
6 /O
No. �) �l �,.,._ %""W ��"�'l ✓ FEF.
COMMON LTU OF MASSACUCSETTS
Board MA.
CERTIFICATE OF COMP.I.LAN'CE
Description of Work: ❑ Individual Component(s) mplete System t
The undersigned hereby certify thatth4''Slewage Disposal System; Constructed}:, Repaired ( ), Upgraded
by CZQ0 .,
has been installed in ccordai► e with the }rovisio is of i0 .CMR .15.00 (Title 5) and t e�roved design plans/as-built plans relating to
application No. rA % dated `� "� Approved Design Flow (gpd).
Installer
Designer C-' :* r l -! Inspector: Date:
The issuance of this permit shall not be construed as a gu r ntee that the system will function as designed.
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No.tOlr� �' (� 7
COMMONWFALT11 OF l SS)AG,I SETT..1
S cam. -5L
Board of Health,
DISPOSAL SYSTFM CONSTRUCTION PERMIT.'.
Permission is hereby granted to: Construct Repair{ ) Upgrade( ) Abandon( ) an tndiyidual-swge disposal system
at. C,+I..r as descnbed to the application for
Dis osal System Construction Permit No.
P Y �� �� ,dated
Provided: Construction shall be completed w thin/ pea of the, date of this pe�/mA. All local conditions must be met.
Form 1255 Rev. 5/96 A).4.Sultrin Co. Charlestown, MA Date �' / Board of Health j� �(
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