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HomeMy WebLinkAboutApp-Permit-ComplianceIWVn`-M"C- x$_630L, FEE/O-100 COMMONWEALTH a MSS SETT c43� Board of Health, Y®4,�'I� , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Constructgr epair( ') Upgrade( ) Abandon( ) - 3 -Complete System 0 Individual Components Location C Owner's Name , Map/Parcel#_ 1 Address �-- r ` L Lot# Telephone# rJ s. Installer's Name C, !S _ Designer's Name 54Q AM) C44Q t • # , 144 AddressAddressAl r e o 14 ec. Telephone# k4ol, Telephone# =,^ Type of Building �_S jcl{�_�C�, __ Lot Size y&_9 sq. ft. Dwelling - No. of Bedrooms 611b Garbage grinder A) o Other - Type of Building No. of persons Showers ( ), Cafeteria Other Fixtures Design Flow (min, required) gpd Calculated design flow �YVO Design flow provided Y4" gpd Plan: Date a_ Number of sheets Revision Date Title Description of Soil (s) `jW,!K_ ,- = L� Epi 6► s YE =-Zj�z 'C /t oZ n-6 04 G 05A 3 � ��/3� p1�" Soil Evaluator Form No. Name of Soil Evaluator 1E7L4Wt Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place theto in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. -�""L-P ��FEE �I. Q COMMONWEALTH OF MASSACHUSETTS kl 3-71 Board of Health, `_/h91' z) u1n4 , MA. 04 CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) A'1 ompiete System The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired { ), Upgraded ( )> Abandoned ( ) at has been installed in accordance with the provisions of 310 -CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated 1 `4-pproved Design Flow K -x (gpd) Installer J, Designer: ,a .. (`Inspector: Date: The issuance of this permit,shall rot be conktalued as a guar a that the system will function as designed. r - No. i�FeJl� t�� �`V�'?i �� 4^^` FEE f.ls': 0'1 COMMONWEALTH OF MASSACHUSETTS Board of Health, Y A 1,M4 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to 'ConstructiX Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at �.$�� D? t �) as described in the application for, Disposal System Construction Permit No. s� cr, dated C�` ` Provided: Construction shall be completed within tL s"of"f�ie date of this permit. Ql1ocal corWitions must be met./ f l Form 1255 Rev. 5/96 A,M,Sulkin Co. Charlestown, MA Date't � I�Board of Health c }