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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13 C -D -TR r r G ` 00 q-9 3 9 FEE 4QV�C)© COMMONWEALM Of MASSACHUSETTS � Board of Health, VhW h (M4 , MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTI®N PERMIT%r�/ /X A plication for a Permit to Construct( ) Repairk Upgrade( ) Abandon( - ❑ Complete System Individualo�neritst!/;t Location £C j)P, (PT WOp CAjU1!-::� Owner's Name I6SQ2j4jXC- --rlAjA40AJ Map/Parcel# ;,L 3 Address ((g p jk(4:Tj 60Z) LA)JG, S ,Nl Lot# Telephone# Installer's Name E r p l LCj1Designer's Name /Q Address`S (+� Sv Address Telephone# -� Telephone# Type of Building R LCSI J)W T I j0h- Lot Size Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures . Design Flow (min. required) Plan: Date Title Description of Soil(s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to a the tem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 3 _q -;?-0 (4 Inspections No. � '441, FEE 16, Z— C®NIM[® I.TII O'f M ASSACHUSETT56 Board of Healtl(, }�bl1l , MA. %�� / �A41 CERTIFICATE 0COMPLIANCE � t.�(i.S !�-'•,��1/`EQ� f � C Description of Work:.Individual Components) ❑ Complete System a /�? i► 'Owe The undersigned hereby: certify that the Sewage. Disposal -System; Consnucd ( ),"Repaired ( , Upgraded( ), Abandoned ( ) by I!'-- . fM"r .17,9V 0,0 <C =r -A i at (� has been installed application No. _ Installer C.,ffltf E dated Designer: WA The issuance of this permit shall not be constri ):)JD-�].]O�.-nJ00 �.�J JL �1 .., ��,,..,t.M"_, 'YLQi�.,7. (1C Jcl ., .�1�•��,: No..�r�©3 C! of10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to /,P::" ,;' Approved Design Flow (gpd) Lam. ` , 3 Inspector: Date: J �f id asi a guaranthat the system will function as, designed. JOOCI 7 f�.. J�:•. u�vO DOCOJOc,-O.. fJ00�-'JOCi ;`. 6-i.o o v"UL YJJOEI5J .. 0..0000 0O00000000 n: OJG7C 0000i . FEE , 00 COMMONWEALTH Of MASSACHUSETTS SETTS ( Board of Health, 1•,nb111:11 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) RepairO Upgrade( ) Abandon( ) an individual sewage disposal system at i ( W4:r f�J L1�4)l1 �' as described in the application; for Disposal System Construction Permit No. t1, dated 4-- �^ Provided: Construction shall be completed within t'arof! tie day of this permit. All local conditis must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board of Healthy �' ,f