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HomeMy WebLinkAboutApp-Permit-ComplianceNo. bo 1/C-48-6GJW 161x + ' — ` T — "-t&OXI FEE' �U®NVV �T� Board of Ilealth, VaNOAMA MA, APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for Permit to Construct()Re Repair( UPgrade'YI/bandon Complete System O Individual Components Location iq Q ` (�/� Owner's Name I C.�tcti Map/Parcel# C�i Address Lot# Telephone# U. Installer's Name IVVJ Designer's Name A-i m 5 y4t 5l � Address �' U Address V �' ` Y10kAhu Telephone# - I [ Telephone* 5o8- 400 Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ C)ther Fivtlwps Lot Size sq. ft. Garbage grinder { i No. of persons Showers Design Flow (min. required) -33 o gpd Calculated design flow Design Dow provided © gpd Plan: Date Number of sheets Revision Date Title "" Description ofSoil (s) AL. .zLLdeu�o u Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undeed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a e s to not Tflace• the �tyem� �m operation until a Certificate of lomiltuice has been issued by the Board of Health.. Signed Date r CJ Inspections 1013 C)ZWt 4 FEE -5 ' . > ®I [�1[O1N I.T I O '� SIJ� TT t,S Board of Health,Uc,V� Description of Work: U Individual Component(s) �d Complete System The undersigned here certify that the Sewage Disposal System, Constr acted O Repaired ( ), Upgraded andoned ( ) by: ' ,4inlj( at 11 Ve t has been installed�1 accor a et= ith the rovisions o 0 CMR 15.00 (Title 5) and proved design plans/as-built plans relating to application No. �' 1C 1 6 , dated ~'�?� f Approved Design Flow (gpd) Installer' ' t A I1 {' Y Ceb l l '4' ajM 1 / Designer: A -A i-A 64e, t} 1 f Inspector: j04AaDate: The issuance of this permit shall not be construed as a, guarantee that the system will function as designed. jll No�i:'(1s"4# �;�1� 71j '�"1e�_G,•Er4ta4ij'�"` 4 -- — FEEr�r d. f`4- - �° COMMONWEALTH Of MASSACHUSETTS j-*- 1IZ:7i Board of Health, 00: , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted t o; Construct( ) Repair( ) Upgrade(- '""'Abandon( ) anindividual sewage disposal system at v-I Ref wt tl ` r� ( ( as described in the application for Disposal System Construction Permit No. 4r dated Provided: Construction shall be completed within three years of the date of this perrn4. All local condit}o s must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date f'^°�F Board of Health r