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HomeMy WebLinkAboutApp-Permit-Compliance6- -'7- 46E0 No T / l — / 9 ��`�EE �J ✓l.' v MMONWEALTH OF MA -SS C14USETTS r�l�3Z lkwmexA MA. ?�/-- &PPLICATION FOR DISPOSAL SYSTEM CONSTRUCT109 PERMIT Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) - ❑ Complete System ndividual Components Location '--v. u L*n Owner's Name Map/Parcel# /,O% 'A Address it Lani' 0 1 h � Lot# 5 & - Telephone# j _ 0-3&-' Installer's Name cMa Designer's Name&u.,n am - Ad p� ya 7�� M-5�5�� �G10`l Addressg3 Telephone# 56 '-- Telephone# hn-:;L-39 Type of Building Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures i, Design Flow (min, required) 7U gpd Plan: Date 2i11 e. 6 Number < Title ' j , i-('2 6-e,i„rs. `P , Description ofSoil(s) Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Lot Size � sq. ft. Garbage grinder { No. of persons Showers ( ), Cafeteria ( } Calculated design flow Design flow provided gpd beets _ Rev'sion Date )1 i -50LA MA Name of.Soil Evaluator Date of Evaluation The undersigned agrees to, above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to ace system in operation until a Certificate of Compl73c has been issued by the Board of Health. Signed — Date � Inspections ��) r1�j A-2-al��a���� No. © C ( P -O 1 Board of Health, /fie a" a^r7eit A , MA. CERTIFICATE OF COMPLIANCE Description of Work:• Pndividual Component(s) O Complete System MA P r Ze,*Il The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( Upgraded ( ), Abandoned ( ) by ! �� s. at K . K 1 0e,,-ik � i ,`' i hl� 500-, VIi A A,AW%C4Tk has been installed in accordance with the P rovrsr s o 1. CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to application No. i � ' +E3 dated �. Approved Design Flow_ � (gpd) Installer rrr> csf .a. r r 4�r[��!. '� Y., Designer: kbien , o 'r�4'lL.Inspector:. P#,4`,!9 /Z tui Date: _ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. _ Q _0 ��..!9 %L- i,.a cd j n COMMOINWFALT14 Of MASSAC14USETTS t! Board of Health, l ex.y,�v a'�i.x •, , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE. Permission is hereby granted to; Construct( ) Repair , Upgrade ( ) Abandon ( ) an individual sewage disposal system at l ei.. ` > - v as described in the application for Disposal System Construction Permit No. , dated !�1 4 Provided: (construction shall be completed within rs th ate of this permit. A11local conditions must be met. f r Form 1255 Rev. 5/96 A.M. Sulkin Co. Cha)lestown, M D to Board of Health 12