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HomeMy WebLinkAboutApp-Permit-ComplianceNo. V�`��5-618b FEEW COMMONW�ALTH Of MASSACHUSETTS 6&"-Zv G�PCAVTION Board of �Iealth, �>�1/� Di��}} MA. A P FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade�AbandonO -'E] Complete System ❑ Individual Components. Location 1vr�-x iii Owner's Name r t�'d3-rj Tf{ Map/Parcel# ISO Address lot /J . 2 a t // % vl + 7 A I Lot# Telephone# sa&- OW �V 0 rj � �o <�' a&-;- Installer's Name �; �� ' cc-' V�— Designer's Name 1 -77 Addresser !�'i�rl Address Li Telephone# (pAin Telephone# Svc S(d r2Z-i"14",1. Type of Building Dwelling - No. of Bedrooms. Other - Type of Building Other Fixtures Design. Flow (min. required) Plan: Date G �-rZ.. . .1 Q' Lot Size sq. ft. Garbage grinder ( of persons Showers ( ), Cafeteria ( ). 9 gpd Calculated design flow Design flow provided __ gpd Number of sheets Revision Date Title Description of Soil (s) SQt _ Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS E -e The undersigned agrees to inst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 -and further agrees to not lace a sys min til a Certificate of Compliance , has been issued by the Board of'Health. Signed Date es Inspections o- al&c J �] FEE COMMONWFALTH OF MASSACHUSETTS� z o z,o Board of Health,V �A� M! , - CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 006 inplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgradedd..�rA' iandoned ( ) by < i ). r. ). ..r , t�C= _ at 4E "A iii ti's"`• �r'� pi,.etie :�f Yom% f- i ..� t'-...1 �''1 ly-, i has been installed •n ac ord• ce with the provisions o 1.0 CMR 15.00'(Title 5) and th--e--ap��roved design plans/as-built plans relating to application No. f ,dated Approved Design Flow Flow, Installer ( vii l r r " �. Designer: c.y s )t tit e O >.pr. v r ( r' Inspector: // o (. 1 ys r` Date: ��v The issuance of this permit shall not be .construed as a,guaran'tee that the system will function as designed. No. _ .. i E� � .-(916! 5 4 t -t v %tC 3: > FEE e .` v � V - - COMMONWEALTH Of MASSACHUSETTS � • �� Board"of Heahk A o 1 ml , MA. DISPOSAL SYSTEM C®NSTRUCTI®NT, PERMIT Permission is herebygranted to;, Construct( ) Repair( ) Upgrade{ Abandon( _;) an individual: sewage disposal system " Cc t. � �p fc, ,. �� ^ Y � •� ' '1 r' as described in theapplication. for Disposal System Construction Permit-�.. I dated Provided: Construction shall be completed withirt4br&vim®®f e date of this permit. -� All local conditions must met:. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date J Bp aril of Health l ,f/1