HomeMy WebLinkAboutApp-Permit-ComplianceNo. L
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FEE
COMMONWEALTH Of MASSAC14USETTS
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Bald of Health,
APPLICATION FOR DISPOSAL SYSTEM CVmplete
RUCTION -qT�► 8 2019
Application for a Permit to Construct( )`Repair( ) Upgrade( Aban( don - System ❑ Ir dixidffWa'ts
Location�(
,
Owner's Name
41 9I^ J `oi-1
Map/Parcel# 7
Address J7
Lot#
Telephone#
-77i�`-
Installer's Name �l . .C�
Designer's Name , ' 4 . r�
Address
Address
Q . Ll &'3
Telephone# JG�
Telepho e#
sd
Type of Building Z�/,;
Dwelling - No. of Bedrooms
Other - Type of Building 1!
Lot Size .� CJ0, " Vsq. ft.
If
Garbage grinderAp
Showers( ),Cafeteria( )
Other Fixtures _
Design Flow (min. required) J J gpd Calculated design flow 36-1 Design flow provided J� gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) S od L!%
Soil Evaluator Form No. Name of Soil Evaluator /4///,e
DESCRIPTION OF REPAIRS OR ALTERATIONS cY--e e 7 J' G. 0"'O� rr
of Evaluation _
The undersigned agr to tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to pl a the temVqaii until a Certificate of Compliance has bee 'slued by the Board of Health.
Signed Date
Ir - ti e
Inspections
No:+ \.' ,i -(�^ 1�9 FEE s ,
COMMONWEALTH OF MASSACHUSETTS
Board ofHealth,....... /} i10 on , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O > Repaired ( ) , Upgraded ,"Abandoned
by: l- f i 3 G m'y fi-4/,S t^ %Ti
at 'C, A!Git ,'� ov r i
has been installed a acc rdanc.e with theprovision-9 of 310 CMR 15.00 itle 5) and the ap roved design plans/as-built plans relating to
application No. _ �, dated F '" Approved Design Flow (gpd)
Installer " " i i �tJ t' �'JJ f�7 l _..
Designer: L41 Ncl- P'Lr /� Inspector: 1 "s U Date: F
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. 1 !
No. s -_ ��Cca FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Healtla, A -P- m Mf MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at f`11 !t 4 �^l c? mit Vit' G c as described in. the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within Cllr .Pref the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date - � oard of Health