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HomeMy WebLinkAboutApp-Permit-ComplianceFEE' rt� COMMONWEALTH Of MASSACHUSETTS C"61780 Board of Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application f r a Permit to ConstructO Repair( .) Upgrad AbandouO Q Complete Systeja Individual Components. LAS 4MF IC4� s5 E'SSo ?-S A bD a ES03 : 3 l 2 w MMSY� GIZAlr 2D Location 3 % w 3 I g 1 )n,516 \ ! Owner's Name DCM D - Ma /Parcel# p L Address,3 %' � $ 1�1! n6 low 6r*V e0 ov Lot# Telephone# t7 y - �,3�% •- (�j q 7 z Installer's Name � a Vo - f 1.0 o Designer's Name _D arrcll cr Address �.i� `7' r Address 1301C q 8i ' G • 67&f ow1ch MA Telephone# _ Telephone# X08 3 02 •- 2'3 Z _Z Type of Building K 1t__ J i C o 1 (e Lot Size sq. ft. Dwelling - No. of Bedrooms T Garbage grinder Other - Type of Building No. of persons Showers( ) , Cafeteria ( ): Other Fixtures Design Flow (min. requir d))i gpd Calculated design flow Design flow provided pd Plan; Date 27 b Number of sheets Revision Date Title Description of Soil (s) A A Soil Evaluator Form No. Name of.Soil Evaluator 1 �2y"9 C Date of Evaluation 919107 DESCRIPTIONOF REPAIRS ORALT RATIONS d -b 3 d h �7 v© 4 --ham t� /�� / The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the >provisions -of TITLE 5 and further a t to place the to 7ooration until a Certificate of qompliahce has been issued by the Board of Health. SigneDate Q 2 " Inspections 3 No, li l k �t, . 3-7 g"' `FEE 00 COMMONWEALTH OF MASSACHUSETTS Board of Health, yuim In- , MA. CERTIFICATE Of COMPLIANCE Description of Work; C116aividual Component(s) Q Complete System The undersigird here y certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded k_4-, AGandoned ( ) d has been installed 'n accordance with the rovisi is ol 3 . CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to appot3 No., I. "' (� J dated Design Flow• (gpd) licati Installer Designer: t % inspector: �" tom1. _ '�� " Date: The issuance of this permit shall not be construed as a gu a -e that the system will function as designed. No. -25-37!`" FEE W COMMONWEALTH Of MASSACHUSETTS Board of Health, VAX M 0 4: 1,, MA. DISPOSAL SYSTEM C®NST" RUCTI®N TERMIT Permission is hereby, granted to; Construct( ) Repair( ) Upgradej,•-y Abandon( ) an individual sewage disposal system — f 4 r (l r t r e at _.'�j i lr_; "t.%-) i I J r ':i (A 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 perm . All local con itions must be,met. - ,y 7 Form 1255 Rev. 5196 A.M. Sulkin Co. Charlestown, MA Date' Board of Health