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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 041--7-41? FEE -7,�TSETTS Board of Health, MA. APPLICATION FOR. DISPOSAL: SYSTEM CONSTRUCTION PERMIT Ap lication for a Permit to Construct( ) Repair( ) Upgrade (vl Abandona-cll-mplete System ❑ Individual Components 0 Location 1 -,!n,Pd � , Owner's Name ^'-y=, Map/Parcel# Y6 C-/4(Address Lot# Telephone# ,� -3 _ s Installer's Name _ c.e 5 Designer's Name, J-'.- 0�4--S Address �© — �. ` Address ( x -- 37 Telephone# _ c� Telephone# � �� -/� Type of Building s Lot Size W V^rirrr$ 4q--,ft- Dwelling - No. of Bedrooms - Garbage grinder ( } Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 7)Z(2:> gpd Calculated design flow Design flow provided 3 5 gpd Plait: Date �� `� ( -7 Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator `Zs . Date of Evaluation - 1.3�=-2f/ 7 DESCRIPTION OF REPAIRS OR ALTERATIONS l S©p - A iti vJ ` S k+ w�---�C, � ro =� � �' �1- a' ray -i�� � ��..a .ice �..� ��� � G l.iv4.nti�,r� '�✓/� � 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 o 4����. r Date �— Inspections No. f2 09-S)C I ZZ SACH*Ti Nz,/`// .FEECOMMONWEALT14 OF MAS _ e^3�•^. �� Board of Health, , MA. 0 CERTIFICATE Of COMPLIANCE-. Description of Work: ❑ Individual Component(s) ;11tomplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (✓f Abandoned ( ) y.... ` A �. .., . _ at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. F dated Approved Design Flow (gpd) Installer�. .m''f y , Designer:Inspector: Date: at_ ✓ The issuance of this permit shall not be construed as a guarante6,at the system will function as designed. No. 6 t, FI Ii � ^ � �_ t,� (Z Z- I`. D� 120C) -OL FEE -7- I> COMMONWEALTH Of MASSAC1 USETTS Board of Health,Til � , MA. DISPOSAL. SYSTEM[ CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system at ' �-*c t� as described in the application for Disposal System Construction Permit No. '../-�, dated Provided: Construction shall be completed within " of tl date of thisper t. All local corMitions must be met. G Form 1255 Rev, 5196 A.M. Sulkin Co. Charlestown, MA Date - 7 r pard of Health f