HomeMy WebLinkAboutApp-Permit-ComplianceNo. DCs ( c%�Z(o�'v .. --60 1/8 FEE' sV
,9- C�,PONWEALTH OF MASSACHUSETTS
Board of Health, O l�I �'�' MA. y
-� APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade^ Abandon,( ) - ACompleteSystem ❑ Individual Components.
Location
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5 A
Owner's Name
�1214^f 14 e - y vI Nth
Map/Parcel#
3 / ZO 6
Address Sin C�
Lot#
Telephone#
Installer's Name
S;?CAV"n/ J)CC.AVA-II
Designer's Name
AA..,A Spy fyK/4,4.�
Address ' S
004v",4-)
Address is
5PE9 W -/x''1 YVAX4t M
Telephone#
0jP1,4z,)?Cjj
So& 432— SS—LY—Telephone#
Sq
Type of Building Lot Size 1j,)4? sq. ft
Dwelling - No. of Bedrooms 3 Garbage grinder {
Other -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min, required) 33 O gpd Calculated design flow Design flow provided 376-6 gpd
Plan: Date # /1.1 1'1 Number of sheets i Revision Date//�
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of.Soil Evaluator -0 /"5W Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1000 C4L iu P Cnom $63e D r z3ex -t 54e
The and' grees to install o e described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a des to of to plac�th sys in operation until a Certificate of C rinpI'vy
nce has been issued by the Board of Health.
Signed Date 1
Inspections 59 zai c4c�'.—
No. E o kiTc--19 ' A;3
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n
OD -E
COMMONWEALTH Of MASSACHUSE
Board of Health,
CERTIFICATE OF COMPLIANCE � ,-
Description of Work:` 0 Individual Component(s) ❑ Complete System t .y
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ),Abandoned ('
at
has been installed in acco dance with the rovisions of 310 CMR 15.00 (Title 5) and the ` pproved design plans/as-built plans relating to
application No. i, dated % v f�j .Approved Design Flow /„(gpd)
Installer
y,. P
Designer: ) i,- r-.y,,AC,j Inspector: k�) � � Date:_��
The issuance of this permit shall not be :construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, V i , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
FEE ' e
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( Abandon ( ) an individual sewage disposal system
at Z5 -a k-yA)S HAI I L" r 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 permit.. All local conditions must be'met.
Form 1255 Rev. 5/96 A.M. ulkin Co. Charlestown, MA Date4 l� %- Board of Health