HomeMy WebLinkAboutApp-Permit-ComplianceNo. �3o N DC�[Cj r7y 1 'V GbTV-- 19 -0 V -7 FEE 4�Xo
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Board of Health, _ _, MA.
rDl 'APPLICATION rOR DISPOSAL SYSTEM CONSTRUCTION PEP01!5�f
�,l Alplication for a Permit to Construct( ) Repair( ) Upgrade /p Abandon() - ❑ Complete System dividual Components
vocation: _
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Owner's Name CLrLt
ap/Parcel# �' -
Address p
OO It
TLinstaller's
Telephone#
Name kh
Designer's Name
Address 1�� _ Lka_SkkLAddress
Z D.
Telephone# -
Telephone## lA u r) 11- gst�
Type of Building9ok-L Lot Size 1 7 � _ sq. ft.
Dwelling- No. of Bedrooms Garbage grinder
Other -Type of Building No. of persons Showers O, Cafeteria
Other Fixtures
Design Flow (m' . required) gpd Calculated design flow. - Design 'fiowprovided 33�"`7 gpd
Plan: Dnate 1 Number of sAhe�ets p ��i Revision Date
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Title 1` i�i 1 C {i� lL (l/.(IL�In j,ip/� D'1�01.Ci 0 �. iqf iju -
Description of Soil(s). 1$
— I vi n., i' t n.'.,.'ri P ,
Soil Evaluator Form No. -J S W % t Name, of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
KDate of Evaluation
The: un rsi agree to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 51 and;
further a to not pl the system in operation until a Certificate o Co pliance has been issued by the Board of Health.
Signed, Date
Inspections
No. '.4U ii � - I : //
.00
COMMONWEALTH OF MASSA HUSETTS
Board of Health; , MA.
CERTIFICATE OF COMPLIANCE
Description of Work:Individual Component(s) 0 Complete System
The unders'ned hereby certify that the Sege Disposal System;,Constructed ( ),Repaired ( ), Upgraded (.�j!Abandoned
at MQ I l `dam, APII �1jed
has been installe ace dance with therovisirons of 3 0 CMR 15.00 (Title 5) and the .aper ved design plans/as-built plans relating to
applicatio Na`dated -?""' . Approved Design Flow gpd)
gpd)
Instalier I i KIN S Gt
Desivner:7V-7 V -Q". LeW1Z LAM M Inspector:: -- --� t///,P Date.: /
'The issuance dAY this,;per#it shall not be construe&as a,guafadtee that the system will function as designed.
No. 00 is D C _1 ' --3 Llf }O FEE v
2- COMMONWEALTH OF MASSACHUSETTS
Board of Health, ymmmf , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to: Construct( ) "Repair( ) Upgrade( ---3' Abandon( ) an individual sewage disposal system
at I S l (-L b IN4141- as described in the application. for
Disposal System Construction Permit No/ -/f'2-- , dated
Provided: Construction shall be completed withix14;U�Vs of the date of this permit. All.local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sultrin Co. Charlestown, 1A Date 1� Board of Health /� f