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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �o FEE COMMO W LTff 0 MASSACHUSETTS Board of Ilealth, P MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct( )`Repair( ) Upgrade Abandon( ) - Complete System Q Individual Components Location 7 1 L✓ L I¢ Owner's Name c© N 2,03" ` Map/Parcel# 9 Address 11 V -mAP Lot# Telephone# Installer's Name aot- Designer's Name' .4iT Address �._. �O Telephone# _Q Address Telephone# _a,7 A-40 E A906614, Type of Building RG -Si DIWTI A -La Lotsize tg#600 sq. ft Dwelling - No. of Bedrooms Garbage grinder Other - Type of Building, No. of persons Showers O , Cafeteria orhf-r Fixtures Design Flow (min. required) 33gpd Calculated design flow Plan: Date 0 I Number of sheets Title 12 ilAP'i'i A KJ 'D iWI AL AOAb Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator E Design flow provided -3,50 gpd Revision Date Date of Evaluation's DESCRIPTION OF REPAIRS OR ALTERATIONS qWnQb4.L- M�— ) I SeO 6641L-49) PCAir—(C-- &AM - 11. Aa.r i+v �.ea The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to o place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed _ Date Inspections 1 V Bta r 'g J= COMMONWEALTH OF MASSACHUSETTS Board of Health, )AgNQVn , MA. CERTIFICA, - OF COMPLIANCE FEE 0% Description of Work: El Individual Component(s) ❑ omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (y, Upgraded O, Abandoned by: "`(---2rDG- "` at`d4�T iA.rP.l has been installed in accordance with the rovisions o 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No., , dated - �� r % Approved Design Flowd) Installer t Designer: $4.16 orf_ Inspector: { , e'ri'' iL ,1� Date: The issuance of this permit shall not be construed as a guarantthat the system will function as designed. f � COMMONWEALTH Of MASSACHUSETTS Board of Health, 'SA D QT# MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE 001 0 Qom.. Q Permission is hereby granted to;, Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at( � "T �6 C�4 + t �.-PscizCbas described in the application for Disposal System Construction Permit No.'` dated ' P Provided: Construction shall be completed within rs of he date of this pert it. l local conditiom must be met. Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Datef 1 7 f Board of Health •' L