HomeMy WebLinkAboutApp-Permit-Compliance No. Bo 1i te.-19-'72iy FEE 0 6520
/ co - a,c'6) COMMONWEALTH OF MASSACHUSETTS - Obit-2679
Board of Health, 16701,017111 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System 0 Individual Components
Location 4 j(iL 1 A ] Owner's Name C k 7 V a( A)c
Map/Parcel# (,i Address .14 j u p� t 11y W f j Y 111/4,,
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Lot# 1 Telephone# n.114)
?5'%�2- U 1 U
Installer's Name !U,tyr-S' G�j��;1/1 r',\ Designer's Nam 1
Address Z.cj .FD t` ,ivi I t�1 4 '�i.ficit ! IAA Address
Telephone#4 1 „gilt,- hC/lg. V` Telephone#
V
Type of Building J Lot Size sq.ft.
Dwelling No.of Bedrooms 3 Garbage grinder( )
Other-Type of Building No.of persons Showers( ),Cafeteria ()
Other Fixtures
Design Flow (min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
� s-c /2_,
U �,� t" I
DESCRIPTION OF REPAIRS OR ALTERATIONS � p�j
The undersign. a ee t: install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a: es r of t, p1: - the system in operation until a Certificate of Comp ance has been issued by the Board of Health.
Signed ( Date 11iJ2., /Je
Inspections
IV
No. &MX-19- /Zy V V( +� FEE i t7`�'co COMMONWEALTH OF MASSACHUSETTS 9
IR - 61°f Board ofHealth, , MA. --v R "'�` �rV t
Y/WitlEnhlr
. CERTIFICATE OF COMPLIANCE 0 44 /
./Description of Work: XIndividual Component(s) 0 Complete System
The unde signed hereby certify that the Sewage Disposal System; Constructed ( ),Repaired 64,Upgraded ( ),Abandoned ()
by: J\l � '€4 ' h tk
at l4( J� Y
has been installed in accord nce with thle pro 'sions o 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. I1"a4Y' , dated x.71/(. Approved Design Flow (gpd)
1 '' I' 111
Installer uiy\t.:� -\ &VLL �
Designer: 'Inspector: /06.Z4,/,77-pe://4-14.0/
�� Date: //3,A'
The issuance of this permit shall not be construe¢as a guarantee that the syste will function as designed.
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No. e70bb'v.'i5 72 f FEEi457-5.-00
COMMONWEALTH OF MASSACHUSETTS d z-51 c
,tblml�`5 ei) Board of Health, y0/2i�Cr " , MA.
7 /3 6)1
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Cho
Permission is hereby granted to; Construct( ) Repair(V Upgrade( ) Abandon( ) an individual sewage disposal system
at 14 j {j rhr 14(1
as described in the application for
Disposal System Construction Permit.No. I —,XcIry ,dated 01}%711
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.Sulkin Co.Charlestown,MA Date f 4:7//?Board of Health 13 6- ` -