HomeMy WebLinkAboutApp-Permit-ComplianceDC— q-2_� / ` �/`/ JJZ- — ((-00 7 ! FEE' �55
/9-/0 COMMON&N OF MASSACHUSETTS X 0 7 28
Board of Health, y%W(L7R4 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct() Repair( UPgrad 'Abandon( ❑ Com Tete 5 stem a<vidual Com o.nents
Location if
Owner's Name 4 `! 0 if C. /
Map/Parcel# !'��
Address%
Lox# y
Telephone# r 4fP`b 5?
Installer's Name• �a W
Designer's Name Shy j� �_)14J G
Address gi0 "Fr� V, I �
Address 20 3 Sa lae i�� /D So N,UI s
Telephone# b
Telephone# s a�
Type of Building16,CJ6 Lot Size `S 1/J_ 3
Dwelling- No. of Bedrooms Garbage grinder
Other - Type of Building No. of persons Showers (l Cafeteria
Other Fixtures
Design Flow (min. required) 3XIle = 3wgpd Calculated design flow Des I ignflowprovided gpd
Plan:Date dfP4, z.�Z T 2�01/�' Number of sheets _ Recision Date
Title PX61'24SFID . ;IC_ 61(1/1W
llesci-iption of Soils)
Q h ff�%1 SA t
Soil Evaluator Form No. Name of Soil Evaluator /e 1-44XQ Date of Evaluation
DESCRIPTION OF REPAIRS OR AI TERATIONS L/ I /L.l3e6 �_W �iU4 7WAJe j
The undersigned agrees to install the above described Individual Sewage.Disposal System in,accordancewith the provisions of TITLE 5. and;
further ag=s to oot, to place the system in operation until a Certificate of on pliance has been issuedbythe Board of Health.
Signed, Date C
Inspections 5_/ j_0/ l Z ! ck— k s-ot W 13cy
No. 6 Ci 1 "" ka Y �' ::a i9 n . �.�� �` �! FEE t� 0o; ``t
COMMONWEALTH 1LTH OF. SS CHUSETTS �; 47) 2
Board of Health;. , 1 i Wn4 MA.
, CERTIFICATE Of COMP'LIAINICE
Description.of Work:,fIndividual Component(s) O Complete System �� z kleell/1
The undersigned hereby certify that the Sewage Disposal System; Constructed ( );Repaired ( ), Upgrade > Abandoned
by
at 7-S
has been installed in accord cc with
application,No.,' p9 , date
"t{ _ , , -�
0 CMR .15.00 (Title 5) and the [apVroved design plans/as-built plans relating to
Installer Uc� t_j p)�'aaf [I 'r-1 / rs�tc��r -� �v vrrr
.Designer: 61 6e [-3. 1 Inspector: ie a° Date: 41
Theswatme_of-thisp�ermit:shalLnotbe-construed,as ,Vwautee_that tiesystem_vUU.unchonas,.desiped._
No., �} � �1 � k > �7i`� ! JV FEEL
commoNwrAuu OF, MASSACHUSETTS
Board of Health, k` r+fll}i' MA.
DISPOSAL, SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at as described in the application. for
Disposal System Construction Permit No.r� r dated r
Provided: Construction shall be completed withintbxaaAzGars of the; date of this peen t. 4111ocal c61-
Form
di '�ns must be met.
'1255 Rev.5/96; A.M. Sulkin Co. Charlestown, MA Date(' c� rl Board of Health ,'�'�