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HomeMy WebLinkAboutApp-Permit-ComplianceNo.A' ,6e/ / - ,oV / 1— FEE ®MM®NLTII Of MASSACIIt1SETTs— �- - �� Y �� .� Board of Health, ,� rL`? e.�'r—W , MA. ?�APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT r�✓I�C �p�p A plication for a Permit to Construct( ) Repair( ) UpgradeL.,�bandonO - b Complete System ❑ Individual Components i =a Location 7 -fl 4 Owner's Name tv Q Map/Parcel# Address Lot# Telephone# Installer's Name Designer's Name Address 46 Address Telephone# . ©. Telephone# 7 •- L/ f a Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms . Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures a Design Flow (min. required) 3 J t% gpd Calculated design flow Design flow provided �3 gpd Plan: Date S -0/- 7 Number of sheets Revision Date Tide Description of Soil(s) sem lo&.4 Soil Evaluator Form No. Name of Soil Evaluator 0,a IY4ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 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 thtigtem in operation until a Certificate of Coms�liance has been issued by the Board of health. Signed %2—� ' Date -7- !> q- Z7 Inspections Fri%—/ -7 ,�%/ Q &L C®MM® LT�I ®� MSS��I�JSETTS L'F'��%�'� lr � �i � Board of Health, V4-Je..&D 07 1 , MA. 0��ii'' CERTIFICATE Of COMPLIANCE � , 17 Description of Work: ❑ Individual Component(s) &Complete System The undersigned �hereby by: 43D f at -7 __ __ has been installed in acct application No. 17-4 the Sewage Disposal System;onstructed ( ), Repaired ( ), Upgraded (L,�, andoned ( ) Ste/ f ` 41L -r 7�°.r✓1 i with the p4-6sion�f 310 CMR 15.00 (Title 5) and the,approved design plans/as-built plans relating to dated 7-,2 f 7Approved Design Flow _—(gpd) Installer V/ i X r (2,) f C 1 1, ,r f _ _ Designee: d g f r1°y /"/ r Inspector: L Date: w"Z The issuance of this permit shallof be construed as a guar �thathe system will function as designed. IC 4 j� No. .%/ / �(J ���/�� FEE 7" COMMONWEALTH OF MASSACHUSETTS Board of Health, Yp`i-M607-74 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Con at 9,/Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No. �_/% 7 Provided: Construction shall be completed within dweeaFears of the date of this per rt't. l local con"ons 'ons must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown MA Date /7Board of Health r /. Ai la-/ � J i.�...� � n } ��.,, f l�. �_. i. ✓_ . / � ). ,// �r...f0✓.Cr� fr � i ✓t�v