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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1360DC- (-[ Z L 7(p `�' � ' y� FEE' 00 COMMONWEALTH OF MASSACHUSETTS CA15- w kJ -4 399 Board of Health, MA. APPLICATION FOIA DISPOSAL. SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrades Abandon( Complete System ❑ individual Components Location 1 j U Owner's Name r A _ Map/Parcel# 67'?, NOS p Cj Address Lot#> ` elephone# Installers Name RODKIG4 Designer's Name HOq�-rsd� Nr(f Address , n Address PLO 6&,,-- 68 t C—. S'I+/@ 4JI CV Telephone# 0 �' t? Telephone## 98 g(,0 3'311 Type .of BuildingLot Size . GZTi u!J Dwelling - No. ,of Bedrooms Garbage grinder ( } Other- Type of Building No. of persons Showers ( ), Cafet ria ( ) Other Fixtures Z 41-6 Design Flow (min. required) �� gpd Calculated design .flow Design flow provided gpd Plan: Date Number of sheets _ Revision Date Title Description of Soil (s). Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS .OR ALTERATIONS The. undersigned agrees to install abo a described Individual Sewage Disposal System; in, accordance with the provisions. of TITLE 5 and,. further agrees to t o lace th operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date s �a Inspections. No. t: t°) .1 Ic `E c"; - 9 / `-1 Z O pe - k>e, &E�b 9-0b" FEE . 53 i 1 _- COMMONWEALTH OF MASSACHUSETTS Board of Health; �f./Vi�1� MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Components) -©"complete System The undersigned hereby certify that the Sewage Disposal System, Constructed ( ), Repaired ( ), Upgrade '� bandoned ( ). by: 'D NCI at k ���-- has been installed i Gorda ce with the rov' ions 310 CMR 15A0 (Title 5) and the pproved design plans/as-built plans relating to application No. dated / A owed Design Flow (gpd) Installer N �� .� �f21 ✓ � �"'°" Designer: Met es.. -t' 5005 ) t` IC- • Inspector: Date: The issuance of this permit hall not be construed :as a grantee that the 4sten willfunction as:des�gned., y No. i' (�i 1 ( -2-61-7 FEE J�7. 60 . '07� COMMONWEALTH Of MASSACHUSETTS Board of Health, mo u r r' - DISPOSAL. SYSTEM ICONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system at. . as described in the application. for Disposal System Construction Permit No. 1 �Y dated Provided: Construction shall be completed within t4pee4hof the date of this pe •m All local co di, ' ns must be met. Farm 1255 Rev. 5/96 A.M. Sultrin Co. Charlestown, MA Date Bard of Health