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HomeMy WebLinkAboutApp-Permit-ComplianceNo. $aX-q L`-' { �� , Ji%�i/ j /_. FEE 4 66'00 t 7- COMMONWEALTH Of MASSACHUSETTS Board of Health, Yf"dUT)f , MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT A lication for a Permit to Construct(,y1kepair( ) Upgrade( ) Abandon( ❑ Complete System 40`fndividual Components kation 1,6 ars Owner's Name t Map/Parcel# /'` Address Lot# Telephone#(� 7 ,3 qInstaller's Name 4 Designer's Name Address 37 &4 bmr eej Oksl Address Telephone# % % y O* p Telephone# , Type of Building Dwelling - No. of Bedrooms Other -Type of Building Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soils) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR AL,TERA gpd Calculated design flow Number of sheets Name of Soil Evaluator Lot Size No. of persons sq. ft. — Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation gpd r� ,The undersi ed ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr not to a e the system in operation until a Certificate of Com fiance has been issued by the Board of Health. Signed Date OF Inspections No. q 0 (4(% `l't COMMONWEALTH Of MASSACHUSETTS FEE64 S Board of Health, �-e�ii'la , MA. CERTIFICATE OF COMPLIANCE % Description of Work: ❑ Individual Component(s) ❑ Complete System O The undersigned hereby certify that the Sewage Disposal System; Constructed (%a!Repaired kl OUpgraded ( ), Abandoned ( ) by: n 1 1' A w +at N0 hv(S.e " Pi,d W f has been installed in accorda e with the rovisi ns o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. _Z , dated r Approved Design Flow (gpd) Installer N QUI N_(Q Designer: Inspector: _2t4 (_ C/C.��fi% Date: J / ,f The issuance of this permit shall not be construed as a guaral6e that the system;w l -function as designed. No. 6 OVA" 10 O -1-7-LI ©t^' 1 L), nio)5 LXCAV,A-n d j FEE 1�5o-, 0 �- /Z)COMMONWEALTH OF MASSACHUSETTS dL4 (.3 -7 Board of Health, I - MOLMf DISPOSAL"` "SYSTEM CONSTRUCTI®N PERMIT Permission is hereby granted to; Con struct(t✓ Repair Upgrade ( ) Abandon( ) an individual sewage disposal system at ll "'of S(' 1 �� ��.+ as described in the application for Disposal System Construction Permit No./ 7" ��� , dated Provided: Construction shall be completed within three years of the date of this permit. l local conditionsAiust .be met. J* Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date �i "-'-� r -;&ard of Health // i