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HomeMy WebLinkAboutApp-Permit-ComplianceNo. FEE $ cS S . 00 COMMONWEALTH OF MASS C14USETTS cIZ43("23 Board of Health, Yui MO VQf , MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System e1ndividual Components Location Owner's Name G Map/Parcel# Address 9 MaLi!�]OLocr Rck Lot# Telephone# Installer's Name , C Designer's Name Address ti C S e r L rQ �'I �p� e $'ioto�' G Address Telephone#s L Telephone# Type of Building Rc:� ioAcry- t a Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) Plan: Date Tide Description of Soil(s) gpd Calculated design flow Number of sheets Design flow provided gpd Revision Date Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS y D BOX cPIcxC�/M:=. r�-� � ►/� � � � 7�....l n — Z 7�1➢0 �' / 4-- �i7�i/ '7 .9 . // _;, / 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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 3-) l " MG Inspections No. 10�4DC-�47"C`f�(o -,"y �G1/lFEE COMMONWEALTH Of MASSACHUSETTS ®�t ,6 Board of Health, VAWOUTg , MA. CERTIFICATE Of COMPLIANCE Description of Work: @1fndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-*f Upgraded ( )> Abandoned ( ) by: �, {R F,)(C.cxkJc 41' 0✓.1 at q /71c-� r e --n0( )C r Rr-k- - has been installediri Yeo application No. Installer e w'r S2ie provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated - A� Approved Design Flow (gpd) Designer: Inspector: Z/,/- Date: -3 /& Z The issuance of this permit shall not be construed as a guarante that the system will function as designed e' +,�,� C7b^C'Cl)C U(` .,`l'U C:r �.:�..: ":OI�CV Ct`-C Ok,<1^('©:)GG VO Qnf.ppf t•Q�`[Ui. CC?L4.:Ct No. - �-`1(0-9 1 (a ` U `- A,CAQA-n 0(\,j FEE COMMONWEALTH OF MASSACHUSETTS 3 ( 2�3 Board of Health, A1P= 1111)rW , M. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(vf Upgrade( ) Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. Ao dated B811 I`ll�C . 6 51/( / Provided: Construction shall be completed within th-r-- �thke-9 edate of this permit, All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date � _1 fit f -Board of