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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6t) i C " j 6__qo-5q —64,D 79 — !49 - ®o Y Y, 7 FEE Board of Health, Y�O t n , MA. �&X �' APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT ti Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System, Individual Components Location/ -1>'box XA Owner's Name / Map/Parcel# U l Addres. l �� 4— Lot# Telephone# Installer's Name Designers Nam e�� Address t_ G R,o Address GO &y14 10 A). V14 Telephone# L _ f Telephone# 8 Type of Building Lot Size/ i2,,, -,a sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( } Other -Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required)d gpd Calculated design flow e2 Design flow provided Plan: Date Number of sheets Revision Date Title Description of Soils) _ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS:Z/7ST4 Date of Evaluation S-2 cW4Ad�� t4_,s The undersigned agr s to ' tall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and 11 further agre n oa the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed s DateJr 16 _ r Inspections Nd. e>owDC-4b-10-3q FEE k57 A Vol COMMONWEALTH OF MASSACHUSETTS A# 13 09, Board of Healtla,�} , MA. ©1 CERTIFICATE Of COMPLIANCE Description of Work; vidual Component(s) ❑ Complete System The find signed hereby certify that the Sewage Disposal System; Constructed (/Repaired ("Upgraded O, Abandoned ( } by at has been installed"in a' "cEo-tial application No.62 Installer ScaTy/ f Designer: c— &ta.rlye Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. -- COMMONWEALTH Of MASSACHUSETTS 130 wrth �rAsions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated 2--� Approved Design Flow and Board of Health,Yaamn k rat , MA.. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( W Repair(uj' Upgrade( ) Abandon( ) an individual sewage disposal system at-44das described in the application for Disposal System Construction Permit No. //!orr r �7 dated Provided: Construction shall be competed within of the date of this permr6l l local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date `� Board of Health (� r