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HomeMy WebLinkAboutApp-Permit-ComplianceNo. �f'l/WV� 6L4% 11z --L v-009-gM FEE COMMONWEALTH OF MASSACHUSETTS 04�0bgq� Board of Health, 'YAR 8 , MA. P T10 FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT iatroi r a rim to frst ct( R air( ) Upgrade Abandon( ❑ Complete Syste Individual Components Location S , , / Owner's Name LeaF. Map/Parcel# r Address"O.S SN1J r lTM_. 1 � FL Z.SjCG Lot# Telephone# Installer's Name b� ©n Address Designer's Name C w f r Address f �Z67S r Telephone# Telephone#' Sd -362^ Type of Building l ' .ot Size sq. ft; Dwelling - No. of Bedrooms 2- p 5 1 r Zd7 k 2 Garbage grinder Other - Type of Building No. of persons Showers O , 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 Soils) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation Theundersigned a ees to install the above described Individual Sewage Disposal System in accordance with the provisions -of TITLE 5 and further agrees to to lace the system in operation until Certificate of Compliance has been issued by the Board of Health. Signed Date - if --� Inspections No. COMMONWEALTH OF SSACHUSETT��rc +� Board of Health, YA (o4 lld"A , MA. �. ,l t�� %�,'� d o G/�- #V CERTIFICATE Of COMPLIANCE Description of Work: ' fIndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded 1(Abandoned ( ) a by:'rte='' z-_rj a eo - Cc. at has been installed in ccordauce with theprovisions 310 CMR 15A0 (Title 5) and the .proved design plans/as-built plans relating to application No , ' f� , dated t3 " Approved Desi t Flow 2 (gpd) d Installer ,. Designer: �>>C :`a 1t l ro f:> 6-,^ �y- (�j Inspector: ✓ Date: The issuance of this permit shall not be construed as a guar '" tee that the system will function as designed. No., �'\yii' �(}2._�: ' f� ,. (,..0 FEE COMMONWEALTH Of MASSACHUSETTS re. Board of Health, V,49MOLM± DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct( ) Repair( ) Upgrade( Abandon( ) an individual sewage disposal system at E j H i j� -1 c(44 —N- . as described in the application for /� n Disposal System Construction Permit No. /� ``rf dated Provided: Construction shall be completed within three ars of the date of this permit )All local conditions must be met. Form 1255 Rev. 5/96 A.M.Sulkin `Coo.. Charlestown, MA Date i�--' ( Poard of Health ` ✓` �°=.�-;..�cz�� s' ;Xs -;`.`!:� :-�.F>rz. G%�;>r.�" � ���r> >A>`rs9�/'� f`;� �iG�i-!�o/C.`✓ fi��t-;2�