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HomeMy WebLinkAboutApp-Permit-ComplianceT3�,J 1 14. ,- I---- VCy` r No. O UC -1(O -61(d0 FEE 0Oyv0� - COMMONWEALTH LTH OF MASSACHUSETTS Board of Health,f71!?�� APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIIT Application for a Permit to Construct( ) Repair( ) Upgrade/(Abandon( - ❑ Complete System jtIiidiidual Components N Location iTs H 0 A 1-e s h AVC Owner's Name d �)QLAA Map/Parcel# IS(773 Address .)At Ar - Lot# CtTelephone# Installer's Name Q0 6e V r ,.t-- C'6 V.Designer's Nameex's Rive- -Z, o-ledc Address 1510,W1 Address A © 90 `J(. Telephone#-.�, Telephone# 6 G4—C1L, L Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Lot Size /0�opo sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Caf;eria ( ) Design Flow (min. required) gpd Calculated design flow 330 Design flow provided Plan: Date I I"' Number of sheets Revision Date Title gpd Description of Soils) AER 86(Z i2nNs �.Oa4 'bel q C ROV-)z 0,oj -A44Wjl U"n 6 A `3-,r Soil Evaluator Form No. Name of Soil Evaluator AMM (601e1 i h�JN e-. Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS MPS % L L b- RCS & Ca4)t Qjy < 4 =N 1 it l'r AY& r S 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 syste in operation until a Certificate of Compliance has been issued by the Board of Health. Signed im_ 6%i Date Inspections No.�� i' 00 COMMONWEALT14 Of MASSACHUSETTS o4—� r �-� E Board of Health, y&eMoiza4, MA. CERTIFICATE Of COMPLIANCE Description of Work: O�dividual Component(s) 0 Complete System The undersigned ereby certify that the„Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,(,.}; Abandoned ( ) by: at has been installed in accordailce with the provisions of 0 CMR 15.00 (Title 5) and t (proved design plans/as-built plans relating to application No. dated Approved Design Flow 6 (gpd) Installer f".N . (S 1 �: P I} t- �Z. 6 V fes- A Z Z) Designer: &AS> P- Y6Y4 etJ&-IA1E(-K-10&-1nspector: Date: �'" The issuance of this permit shall not be construed as a antee t 't the system will function as designed. UOC60t!000(. PGC DOGOQC UC oo``l GC�^..un�,�'OG{�Q C0,000000v'J OCOOD 000000�,e000cocc.0000.coS7o•S�:ooaoo0oe n000 00000 ooc�o-7.000 ob �b�ioo oi',�*e�^�b-r, O°e�: rL`ooo -- No. %� oIA-,D C. i EV 1o1 (0 l.J . 6 . owi- (70 . FEE COMMONWEALT14 Of M ASSAC14USETTS cl -- oo?r-t L13 Board of Health,�iq-�?_,f m ()7}l , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade -C) Abandon( ) an individual sewage disposal system at Disposal System Construction Permit No. to �� , dated as described in the application for Provided: Construction shall be completed within tkrza� of the date of thisperftiit. All local o ditions must be met. Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date 7- % �` BEA of ealth (. v