Loading...
HomeMy WebLinkAboutApp-Permit-ComplianceNo. foac- t /�Z� � /� � � � L � FEE r z� COMMONWEALTH OF MASSACHUSETTS Board of Health, 071 , MA. = �4kICATI®N FOR DISPOSAL' SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(( Repair() Upgrade() Abandon() - ❑ Complete System ❑ Individual Components Location Owner's Name Map/Parcel#32 h75?Address 6�`f Lot# Telephone# G Installer's Name/%t,,,,,Designer's Name Address ! G Address1608AlFar66o,,,02 3 Telephone# rggg 7? Q SV / / Telephone#f - j'®8 ) 2#6-Z220 Type of Building _s) L, Dwelling - No. of Bedro$ Other - Type of Building No. of persons Lot Size sq. ft. _ Garbage grinder ( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided .2 -gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No, Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 5762/1 nPW 41,7� inn 7Q/0 s ctnd '046!2,0 e 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 placeAhe system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed i' - Date InspectionsNo. FE COMMONWEALT14 OVMASSACHUSETTS.) Board of Health, V&9./¢.J O(J ! CI , MA, CERTIFICATE ©FTOMPLIANCE /71 Description of Work: k1ndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed Q<, Repaired ( ), Upgraded ( ), Abandoned ( ) by: &A, -6i%1 s at t{ ld) e� ✓firs �i i•1 �S'L J�111%[ has been installed 'n fy1 ccordan. with th rovisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to .+1 d application No. r ^ ated -/ /, 1. Approved Design Flow-2.Z�-�- (gpd) Installer tAU \1 Z i`\-/ ~ l p a / Designer: . � CLi Inspector: f Date: The issuance of this permit shall not be construed as a guar a that the system will function as designed. No: Q%�tr'1�"L)�i G J �N .� F�.iC� FEE• 7- ,/2, COMMON LT14 Of MASSACHUSETTS % (114 Board of Health, YA �— 112MOUTA MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; ConstructX' Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at �'rPiP .�?C7iP s re,�r�~rof1y �t as described in the application for Disposal System Construction Permit No. / -7- ' 7,- dat 9 I Provided: Construction shall be completed within-� of tVe date of this perm, ;local cot d ti ust be met. Form 125555 Rev. 5/9 A.M. Sulkin Co. Charlestown, MA Date "~ oard� of Health - �� �`7 ;'v /tel t-�.��1/ � 1 ~_ / �f i �.�1' � .� i':+_•�-r-..� f �15'"! .ice