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HomeMy WebLinkAboutApp-Permit-ComplianceNo. /�///��L la n � t! i` /��• FEE' D CID COMMONWEALTH LTH OF MASSACHUSETTS Board of Health, YAMoo-al mi. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT. Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) 0 Complete System dividual Components Location , h v` ,,- Owner's Name Map/Parcel# Address J r Lot# Telephone#,y ro 9 Lj 6 6,S SO4 ,6-3 7 >' � Installer's Name r ` 1 j V j -j4T3 CC -A, 01- Designer's Name Address 1 12 Address Telephone# Gq- Telephone# Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers( ), 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 Soil,(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPT O F' L — 60Q w '- The undersigned ees to install the above desc 'bed Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and further agrees n to a the tem i u Certifica Compliance has been issued by the Board of Health.. Signed Date O No. �.. %i0 FEE ? 16 - �>-3 �- COMMONWEAI.T14 OF MASSACHUSETTS Board ofHealth, 1 4 , MA. 4, CERTIFICATE Of COMPLIANCE �� Description of Work:•"O Individual Component(s) El Complete System.��-- The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ); Upgraded,(- -,-Abandoned ( )' at S-Ct4l ! e--t%� 4b 4- has beat on Noled in acco�da ce with the p 4 is >ns of 31 -�MR 1 . 0 (Title 5) and e approved design plans/as-built plans relating to pp '. dated �,_ p -p—,rived Design Flow - - (gpd) Installer i' i I, S S l''+� 1/ r Date: /l —. /% �,..r- _Oi�� Designer: Inspector: 10-AA . ,2 ✓_ The issuance of this permit shall not be construed as a, guarantee that the system will function as designed. , FEE r COMMONWEALTH Of MA5SACHUSF'TTS Board of Health, -0 MA. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is hereby granted to; Construct( Repair( .) Upgrade ( ) Abandon ( ) an individual; sewage disposal system at J j -C,� r� r d-a. �;;, T ry 1. 17 01 56s described in the application for Disposal System Construction Permit No. dated �d s Provided: Construction shall be completed within three years of the date of this permit. Al local conditions mist be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA D'ate9- -) j 4 Board of Health / l '