HomeMy WebLinkAboutApp-Permit-ComplianceNo., F/" FEE,. Moo
'MMONWEALTH OF, MASSACHUSETTS (:q?.33
Board of Health, )(6rg % u-ni , MA.
LICA ION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( )'Repair( ) Upgrade( ) Abandon( ) - plete•System 0 Individual Components
Location <
A V en ,I
Owner's Name
`r _ r i t io
Map/Parcel#
-T-3,3 _
Address
w
Lot# /4-1
histaller's Name
L Fwd' L���
Des'igner's Name
SWItC� et.✓a�
Address to
15okr ?a Le 5 - y
Address 3
. ed.S. Dc
Telephoi e#
SD -7-7 4,- G ��
Telephone#
_s 7
Type of Building' 1 \ (St'r/��`� / Lot Size 6o7•Se 1. sq; ft.
Dwelling -No. of Bedrooms -rhi z-<_ Garbage grinder ( )
Other - Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures
Design Flow (min. required) j V gpd Calculated design flow 37 Design flow provided gpd
Plan Date �� ai cw Number of sheets _ Revision Date
Title
Description of Soils) U r� lG� T 4� r� [ e—%CY c t l `]! 01 16c�/1Z S�"'t�/J
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS Hui A-1�+C't`.f)`ja�
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 Com ylian a has been issued by the Board of Health.
Signed Date 6 A pZO�
0
No. 60 0 �� "19 -3 , f FEE
®M[�'I®NIT TSCIJS�ETry %,f,,r Li 2
Board o Health V%Ay MA.
CERTIFICATE SOF COMPLIAINTCE
Description of Work: D Indxvxdiial Components) "omplete System
The 'undersigned hereby certify that the Sewa e Disosal System; I Constructed ( ), Repaired (, ), Upgraded Abandoned
by:_�� C -t/ C_4,. c -f C'G
at i e e aM -�
has been installed in acco - ace with the rovisi _nsfo , i0 CMR 15.00 (Title 5) and t e approved, design plans/as-built plans relating to
application No. /r ' ., dated r �� Approved Design Flow � � (gpd)
Installer M�*
Designer: ) y.,, a 4 -Y - Inspector: Date:
The issuance of this permit shall not be construed as a guara that the system will function as designed.
No.#� iC� �J! -Lf„ t�.- FEE 15' 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, A(4A4 ® VT_1+ , MA.
DISPOSAL SYSTEM I
CONSTRUCTION PETIT
Permission hereby ganIIrl"-,
to;; Construct( Repair(
nt 11 A IZ" tai
Disposal System Construction Permit No.�/-
Upgrade
PAbandon( ) anindividual sewage disposal system
as described in the application for
Provided: Construction shall be completed within * : Ws of the date of this r All local conditions must be met.
Form 1255 R�.5/96. A.M. Sulkln Co Charlestown, MA Date ` Board of ealth �-" `� '
0 7'�/,. „,l�, , d 7z. '11�_ ) ��..-�/�' � l�i�•Ce (� f V1,_/. Ago X./_1l