HomeMy WebLinkAboutApp-Permit-ComplianceNo. �C l.� 1 1'�'� I / FEEw
COMMONWEALTH Of MASSACHUSETTS 6k*aO
Board of Health, Ymmb uzv , MA. O(jy�, j�ee,-� 1yo4o C11
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT * --
Application for a Permit to Construct( ) Repair( ) Upgradet-�Abandon( ) - ❑ Complete Systexnl- Individual Components
Location 9
VEVAlzb1-40,9_
Owner's Name C L i O 2(4 a e ro n
Map/Parcel#
a ! �,
Address �° r LtaY_2y lint'l t¢e- a, x*,v V,
Lot#
-
Telephone# 5G sr- Ggy-
Installer's Name o 5 { 5 �n ['�/C L>
Designer's Name ff
d.Cw 1J Cia .Q � L6+1 PP2t� �N�
Address
Sf3�,.A 14�<� je l3reec„SU, rnA
Address
q39 11ZAIN sr•
Telephone#'U�
.� ' a2_63)Telephone#
p 3 a. - ySy G2Ly1
Type of Building fZ eO 4 e� X14 ( `y 1' h `0 7 >� p R a' Lotsize sq. ft.
Dwelling - No. of Bedrooms / Garbage grinder ( )
Other - Type of Building No. ofersons Showers
p (), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date tt't _ 6 1 l 2 t Number of sheets / Revision Date -7 / 7
Title s' [ 4 12 L f 6 t �
Description of Soils)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1/ ' -& I, y 1�x L4
125
The undersigned agree to install th ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t place the em ' operation until a Certificate of Cbmpl' nce has been issued by the Board of Health.
r
Signed Date Zd l
Inspections
A_4No. O'D r 7--05 FEES
/ - C®MMONWEALT14 Of SSACIIUSETTSc ,r � -7,
Board of Health, gpzmoylw , MA.
CERTIFICATE Of COMPLIANCE
Description of Work:tel Individual Component(s) ❑ Complete System (��J �'� A 44
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade Abandoded )
by W,3 ZT 4f -_-Y >T OK)
at 9 r—u\ kc- C``'1 A (2-'D LA lei C—_
has been installed ' i acc r nce with the rovisio}is of/�'10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.7, dated ��j / v .Approved Design Flow. (gpd)
Installer 4<, U E> (-"CC. I .-> • 1 fit.. t-. (_`
Designer: -DC)Vj 1J CA 0�77 Inspector: 1�%Iglw Date: 7 1, ff
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No. 700V-
00 12-02057 FEE S�; 1 11
COMMONWEALTH Of MASSACHUSETTS
Board of Health, �A P_ mo 11-4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No/j� dated& i
as described in the application for
Provided: Construction shall be completed within three years of the date of this p All local condi ' ns must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Health