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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 13e Q> tjVG.' d 5-32- 5 COMMONWEALTH Of MASS CHUSETTS Grob l7 S Board of lkalth, APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) UpgradeV/AbandonO - a-t mplete System O Individual Components Location n , el; -Owner's Name 06eC CQc Map/Parcel# 3 s Address '�: -A AV k— 3T,'K-kiA yyyQsp Lot# 1 Telephone# �` --� '� ■-+ Installer's Name I `O � 2 < g CC) .4r� Designer's Name R Q S- R� Ve Ir � f Address . - _ Address,19 oaO ro�S 2N _ b Telephone# b — ©J DID Telephone# 5 - g. Laar, Type of Building Of Lot Size L �1 r0 sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria Other Fixtures — Design Flow (min. required) 10 gpd Calculated design flow Design flow provided gpd Plan: Date _ �, � � Number of sheets 3 Revision Date Title p Description of Soil(s) >,C) ` (_0 N � , aJ AJQ C C Z 0 ji _ N Soil Evaluator Form No. Name of Soil'Evaluator 'I' 41 L IZC.. a Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS OS- "Ct l I k t S 60 9!2 L TA K J) e The undersigned agrees to install above described IndividualSewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not lace di m in operation until a Certificate of Com liaiice has been issued by the Board of Health. Signed DateV, Inspections ,r COMMONWEALTHOF MASSACHU' - 70 Board of Health, 0'VyrxA , MA. CERTIFICATE OF COMP-LIANC, Description of Work: ❑ Individual Component(s) U'Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded j, Abandoned ( ) by: t� . � " \\ at i L C �- r has been installed in accordance with t e provisions of 0 CMR 15.00 (Title 5) and,; then pproved design plans/as-built plans relating to application No., f dated Approved Design Flow (gpd) Installer Designer: R-ik/E-ER RQ&119 t Inspector: Date: The issuance of this permit shall not be construed as a, gua tee that the system will function as designed. No. P a(`' ate`(" -gC�_ / !�6 6"+1 FEE COMMONWEALTH Of MASSACHUSETTS ik Board of HealtTt, 1i, MA. DISPOSAL. SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(,) Repair( ) UpgradeX Abandon( ) an individual sewage disposal system at ('� L4 M A ' y r) c3&y � as described in the application for Disposal System Construction Permit No.,'`�,—, dated ./ . Provided: Construction shall be completed within three years of the date of this uormit. All local conAitions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date!' '" , ! :a Board of Health L, '"y