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HomeMy WebLinkAboutApp-Permit-Compliance4 COMMONWEALTH OF MASSACe TT Board of Health, OTIA MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT 1:)plication for a Permit to Construct( ) alr ) Upgrade( ) Abandon( ) - ❑ Complete System -ZlLiidividual Components Location 3 © trd Owner's Name ,,re, GJ1' r'71 Map/Parcel# �� �j kilo Address y, •� Lot# % Telephone# Installer's Name oU Lc C�+✓D �fsi. C Designer's Name Address U _3vx s yepolAddress ( 4S�- S4.nc t.r Telephone# G _ 77 - Wg:ee� I Telephone# W ,. j, 3 ) K /s��+ t o Lot Size sq. ft. Type of Building .Dwelling.- No. of Bedrooms Garbage grinder Other - Type of Building No. of persons Showers Cafeteria Other Fixtures Design Flow (min, required) ��i gpd Calculated design flow 30 Design flow provided gpa 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 ORALTERATIONS D <e— ►�/ O'lesur "o %`•h C 1 ove1� 6 TA F; �7✓t• la1 S i.� 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 the system in operation until a Certificate of C pliafce has been issued by the Board of Health. It Signed Date 0 No. w Ix. -'IS-0105-- 6- 4. EE Board of HealtTz, —i l�%��4 ,AM. d 4 CERTIFICATE Of COMPLIANCE Description of Work: :dividual Component(,) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), R aired ), Upgraded ( ),Abandoned at has been installe in aac'/cord nce with the rovisions of 10 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to application No. �� dated �� —(r Approved' Design Flow �pd) Installer e - r - •• � / ,�' Date: Designer: ?-A U. /�'�l Inspector: _ The issuance of this permit shall not be construed as a, guarantee #, t the system wiIl function as designed. No. f - COMMONWYALT14 OF MASSACHUSETTS at Board of Health, _ N i MQJ� , MA. DISPOSAL SYSTEM C©NSTRUCTIONT I ERMIT is herebygranted to; Construct( ) Re aarrrt--T Upgrade ( ) Abandon ( ) an individual sewage disposal system System Construction Permit No. N_ f dated J as described in. the application for Provided: Construction shall be completed within three years of the date of this permit. All local condidggs must be met: . Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date Board Board of Health , i r % • �'