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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1� CSV 90 �/L "�1,� O� �o FEE w r -/9 COMM® � I. S �IIIJS���S a4 - t d 1..1 HEALTH DEPT. ' Board o Health, 1146 ROUTE 2 mAAgV��--OIICATION FOP, DISPOSAMMR ftrMION PERMIT . / f 8�� Application for a Permit to Construct( ) RepaiXUpgrade( ) Abandon( ) - ❑ Complete System5!9�ndividual Components Location C / C /�/i✓ ®�� Owner's Name Co '.%� Map/Parcel# 078, 2 6c3 Address Lot# Telephone# �/,7 "CP Installer's Nameeft`q�®�J� l/ Designer's Name Address e ,� ,G i'� '�� y Address Telephone# ob, j` 6' Telephone# —'T' % Type of Building 60 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) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets - Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS .Pee Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees�to pla a tem in operation until a Certificate o pliance been issued by the Board of Health. Signed CDate oor Inspections s No. & R 1DC _..1 -2 ""00 S 0 FEE � C®�[�[®NI,TII of MASSACHUSETTS © ��. �� 80 % r Board of Health, k�%V a& A �T , MA. CERTIFICATE of COMPLIANCE x Description of Work:A dividual Component(s) ❑Complete System ��( 7 The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), RepairedUpgraded ( ), Abandoned O has been installed in acc0a c-ee .th the pro visi s 9f 40 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to application No. /> dated a / L. Approved Design Flow (gpd) rg Installer Z7A- k �5 7T L -C OPV Designer: D, 15.MASOlQ Inspector: Date: �� .� The issuance of this permit shall not be construed as a tee that the system will function as designed. 04:- /7- 1�7 COMMONWEALTH OF MASSACHUSETTS 3 Board of Health,'rl7 , MA. DISPOSAL SYSTEM CONSTRUCTI®N PERMIT FEE X b-51 CC/ Permission is hereby granted to; Construct( ) Repairle) Upgrade ( ) Abandon ( ) an individual sewage disposal system at �'�%i,'r®/���'� as described in the application for Disposal System Construction Permit No. j' 7 , dated Z - ' 7 Provided: Construction shall be completed withif tth n -or he date of this pe mi/ All local con(Ations must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date / ^ -)� l O Board of Health