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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6 0+11 C -' �-03ZZ V W 1 V1 FEE /W`00 C®MMONWEALT14 Of MASSAC14USETTS �Board of Health,i�iLl�(Ql1"r} MA. TT I-PPLIM;ON L®I, DISPOSAL SYSTEM CONSTRUCTION PERMIT A4p�c tion o� miyt; Cr cteRepair( ) Upgrade( ) Abandon() - ;.)(Complete System LlIndividual Components Location 0 %f, �f/" Owner's Name -1 A Map/Parcel# s- .. Address 8 A"`10-0 i I.ti�TL/1 Lot# Of Telephone# Installer's Name ��.1 MEQ , pt�� M Designer's Name &- ©� Address PJ 0 O C) IJLS ��2.�- Address r / Telephone# Telephone# 4ype of Building, i% ! �7- ,/ Z— 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) S l�— gpd Calculated design flow Design flow provided 4549V gpd Plan: Date l % / U Number of sheets Z Revision Date Title Description of Soil(s)--- Soil Evaluator Form No. Name of Soil Evaluator 141" L. 2Z Date of Evaluation 7�f DESCRIPTION OF REPAIRS OR ALTERATIONS The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr to not to pe the system in operation until a Certificatelo� pCom iance has been issued by the Board of Health. Signed - Date l �f :-t Inspections n h�/ - ✓��,,.-°fit �- No. O C " (6 - )3 ZZ - FEE COMMONWEALTII Of SSACHU- TT .5sG 2 - Board Board of Health, Ya(tmoyr" MA.r� (� �J' 1 CERTIFICATE OF COMPLIANCE o�/26�6� Description of Work: ❑ Individual Component(s) 0 Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed)<r,Repaired ( ), Upgraded ( ), Abandoned ( ) by: 1. t� ( 6i- ch a" at YA _� � has been installed i cco c with the ro x s df" 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. :� dated '.Zr. Approved Design Flow4ffV (gpd) Installer l 'Akk'X (AAVI " 1 i:::" Designer: --1r?;1,-7, C_. (e G, Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 6 oN ID C C +A S rC -t tz-7 FEE C/LJ COMMONWEALTH OF MASSACHUSETTSs� 7— Board of Health, 0 , MA. 51 DISPOSAL SYSTEM C©NSTRUCTI®N PERMIT Permission is hereby granted to; Construct„< Repair( ) Upgrade( ) Abandon( } an individual sewage disposal system at V �')� i l)11 S Vii- f�4 _ •..- as described in the application for Disposal System Construction Permit No.� ''� d -1 ated 7%(/a . Provided: Construction shall be completed within tk��-©f the date of this per 't. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date ,X 1�1 Board of Health ��Ca - a ; �31ic�vy A /0SI&Oy : 1� f Gal'%% ���i/�G� '' ��,r�r�' on411k"