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HomeMy WebLinkAboutApp-Permit-Compliance16 -6,16 3 No.J FEE COMMONWEALTH Of MASSACHUSETTS 6k* -20 53 Board of Health, L' WM©U`��., MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION I Application fora Permit to Construct( ) Repair( ) Upgrade baO ndon- El Complete System .fd'Individual Components Location 1. m -e (O'J- rl c%0 Wa SS h Owner's Name i20I3- 0+Vr Map/Parcel# 3 a- �/ Address Cj �'q,,`� LC d- /l d) Lot# Telephone# 1&09 F Lj 7'Z Installer's Name S 0'0 �g Caw- Designer's Name h. PiGN`7 Address a, � Address (3Gvt Telephone# C (y (� Telephone# yC&- s Glo Type of Building 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) 10� Plan: Date r t �0.9 1 Title gpd Calculated design flow Design flow provided gpd Number of sheets 1 Revision Date Description of Soil (s) 5 -t -f 'Sa r l Lol Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS S' S;1 • nA S i The undersigned a es to install the above describ d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees t t to I e the/sys aon until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. 6014 IDC -1 -10166 COMMONWIFALT14 OF MASSACHUSETTS Board ofHeallth, YA9MM A , AM. FEE �•� sos S l Description of Work: '1l Individual Component(s) El Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade , Abandoned ( ) by; at ct_�' has been 'installed i accordance with the rovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. �- / dated r Approved Design Flow rf (gpd) Installer Designer: ',.r t n ? -' ;'l t Inspector: LV XffZZ•f _ Date: _ The issuance of this permit shall not be construed as a guar ee that the system will function as designed. No. COMMONWEALTH OF MASSACHUSETTS Board of Health,V¢3-, MA l )' M MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( at FEE -- Upgrade") abandon( ) an individual sewage disposal system as described in the application for Disposal System Construction_Permit No. ! , dated6 Provided: Construction shall be completed within ti, �a of the date of this permit. Al local conditions must be met. r Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date f� - Board of Health