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HomeMy WebLinkAboutApp-Permit-CompliancekYf ` YAC,- I 7� COMMONWEALT14®F MASSACHUSETTS Board of Health, YP© (f if MA. FEE 4 ti 0 n a "c;,67 APPLICATION FOR. DISPOSAL[. SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) EiComplete System D Individual Components Location q4-1 A Owner's Name Map/Parcel# O ?>I, 6 Z I Address r Lot#/I A Telephone# 0, g ° l&b _ �,"i Installer's Nameleti sojace .� Designer'Name Ci4sG�, Eos AddressV o�ecl cdc. 1Q�. bJ tar c\ pos e Qy/� Address ,1 ill G 4 a Nvi`� Asnd r A Telephone#' �Q _ y� _ i 06 Telephone# q 9 4..5 qoc Type of Building 4:0 Ukwce-<— C.l Lot Size Dwelling No. of Bedrooms Re-AaA dip cT Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 4 gpd Calculated design flow 1155 Design flow provided 415 _gpd Plan: Date Number of sheets 5'\,,e e 7 - Revision Date Title cam ? TSr—Q k ct S,6-key,C�a 01 -Ac. 1i Description of Soil (s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator q3\— b S v 1% iy Ck" 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 agreu to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ^ �� Date 1'11.-17 No. Q { � 5 � � I 7 fNEE COMMONWILALT14 OF M[SSCHFSffTfir_* 5 7 C., 7-41 Board of Health, W&MOVni MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed Repaired( ), Upgraded ( ), Abandoned ( by:C_:Ono 5e)j Cc? t"' at has been installed in accord ce with the provisions of 310 CMR 15.00 (Title 5) an the proved design plans/as-built plans relating to application No. dated /r Approved Design Flow (gpd) Installer—_�_r„�€t-t,J Designer: l) t Q &Lb O P Inspector: The issuance of this permit shall not be construed as a gua&a Date: —..Z—,6 —/ f that the system will function as designed. No. j6o c -i 7"-2--3~% 9 cot,a ucno" 5ooe-c H6- /7-,/-41 COMMONWEALTH Of MASSACHUSETTS Board (f Health, rwo Lint MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct Repair( FEE - 587 ) Upgrade( ) Abandon( ) an individual sewage disposal systern at ` t -1 / Disposal System Construction Permit No.-, dated as described in the application for Provided: Construction shall be completed jwithin three years of the date of this per it. l,,local co ns must be met. Form 1255 Rev, 5/96 A.M. Sulkin Co. Charlestown, MA Date f ` /Board of Health