HomeMy WebLinkAboutApp-Permit-ComplianceNo,
COMMONWEALTH Of MASSACHUSETTS
Board of Health, )� OTH , MA.
A P1ICATION F® DIS�OL . YSTaEM CONSTRUCTI N�Lo—x Lrl ®SPT
Individual Components
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Gat( .? =0GL--E-D
JUN o 5 2019
Application for a Permit to Construct( ) Repairg Upgrade( ) Abandon( ) - ❑ Complete System
Location r2 U rn(,UD
Owner's Name CGLM i Il
Map/Parcel#
Address ) `� 13 U-01-" ,
Lot#
Telephone# 5o Ff - % % 8 - � l 6
Installer's Name 906x—, Our Co. xe,
Designer's Name
Address
Address
Telephone# 508- 5oj- laoSg
Telephone#
Type of Building 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 Soils)
Soil Evaluator Form No. Name, of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS AP -A We- Q - BOX %)13=3 ( o►'► -n BLT-
__ _bac � s �.►Y�P; p; � �a _
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.,
Signed .9" PD1er r 3.(,x)r 6<1/kf Date 6-1-1`7
Inspections
No. 9 " :i �(� FEE /'.�`sS , 610
V'V'
COMMO JLTH 'USF M, ASSACHUSE S
Board of Health, Y UModnA , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: Individual Component(s) ❑ Complete System
1�
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (v< Upgraded ( Abandoned ( )`
by: szo Ger r Z Ei u r 6P
at 1Z Ak-rnalq ied,
has been installed in accQrdaace with the rovisions of 3 .0 CMR 15.00 (Title 5) and the approved design plans/as,-built plans relating to
application No. , dated Approved Design Flow (gpd)
Installer ' ; ��51-� ; 01'r Co.:E-4n'
/ 9
Designer: Inspector: Date: oris;'
!
The issuance of this permit shall not be construed as a guarddtee that the system will function as designed.
`.. 1FEE
COMMONWEALTH OF MASSACHUSETTS —+j - 0 C, U I V,-,
Board of Health, _� n t))"-tt , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Vf Upgrade( ) Abandon( ) an individual, sewage disposal system
at 12- Zu rn rz 4 ' as described in. the application for
Disposal System Construction Permit No. , ' . , dated
Provided: Construction shall be completed within three years of the date of this Fpenit. _ All local corny itions must be met..
Form 1255 Rev. 5/96 A,M.,Sulkin Co. Charlestown, tin Date � r/�� Board of Health