Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceL U r�� 1 4- �Z-11 e. (41 No. o 6,59���:.'���Q % " `!`- FEE 6014DCA--1 52-2. COMMONWEALT14 Of MASSAC14USETTS "007/6-7 14--31 Y49=MO c �lura. Board of Health,, APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgradq,(>�bandon() - ❑ Complete System J Individual Components Location 571 M 4 Owner's NameTAC-11, Map/Parcel# I a 6 Address l M. L N Lot# Telephone# 3 3 9 - L �, Installer's Name R �., v 1. co�N Designer's Name R V�Fki--tNeeintia Address .CiAA Ck Address Ro ._ Telephone# © _. Telephone# , N!J 1 S _ Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. re wired) 3 gpd Calculated design flow Plan: Date �a i Number of sheets Title Description of Soils) Soil Evaluator Form No. Lot Size sq. ft. Garbage grinder ( ) of persons Showers ( ), Cafeteria ( ) Design flow provided =5:� gpd Revision Date Name of Soil Evaluator M� VO "C Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS I 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 the =ration until a Certificate of Compliance has been issued by the Board of Health. Signed /% Date r�, 1 Inspections .No. 014 DC- 1(0"��22/ /FEE+. �.�.5t00 .. COMMONWEALT14 OF M ASSACHUSETTS pk- �-/,c c 0a-718-7 Board of Health, 0 ON MA. i, y CERTIFICATE Of COMPLIANCE Description of Work:' =®'Individual Component(s) ❑ Complete System The undersigned hereb certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( ) by: Ro6Q r 'j Ccs . :rA) G-. at 51 W- C.OJ, has been installed m accordance wit i the rods n 310 CMR 15.00 (Title 5) and ' proved design plans/as built plans relating to application No. _, dated Approved Design Flow '(gpd) Installer CA+AU57T0 P ft -f2- O U IZ— Designee: ®k5Sw4V�ii Inspector:eL&&&YDate: The issuance of this permit shall not be construed as a guaran a that the system will function as designed. Ovt�ij �; .:7[.^ _ `,:'b C' :•�C^_<t'.c .: ...Y< -. _c.. .,v�`.tt<_:r..c..>tCOG�. c+Cs ,py•r,O�Ur'�i.r�occC SCc,c ..^uCoCt;:.Dt>rJOZ.'. c.4-Gr,.�uc�AO«+1=Ua:-c�0'Oc O.�r, <-:Pi ..aS�oLc]t)C� No. jQ �C_I(o-�rJe L rz 00e. FEE 55'40 ' ! COMMON�LTII OF MASSACIIUSETTS - 0O -7c 3-7 Board of Health, �1A(t-11�101�i�l MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgradez Abandon( ) an individual sewage disposal system at �� (-� as described in the application for Disposal System Construction Permit No. 1�Ci -� , dard 46-4 Provided: Construction shall be completed within-th-r-e�s of the date of this permit. All local condions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date /,$oard of Health I