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HomeMy WebLinkAboutApp-Permit-Complianced No. Bo 47DC- -'314 57' f5j oTV - j "l' 06-7 133 FEE; 1�(,Q0 COMMONWEALTH Of MASSACHUSETTS a ycf 6 Board ofHealth, - �i pur mc)u.Aknom b . • . APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( AbandonO - complete System O individual Components Location_I rc� c w Owner's Name Q, v v►r K � Map/Parcel# Address Lo Lot# Telephone# Installer's Name ,� F_XcaomA 10r\ Designer's'Name AddressAddress 14 ca5ct' L r-3 Orc A C_ n P. O. O arW,Ck Telephone# Telephone# 7914 _ 99 q_ ILI Type .of BuildingRes, J ag72j Lot Size sq. £t. Dwelling- No. of Bedrooms 2 (3Cjr00fV\ _OcS.orn -Q' r ti j Garbage grinder ( } Other -Type of Building No. of persons Showers (' ), Cafeteria Other Fixtures. Design Flow (min. required) Z ZO gpd Calculated design flow Design flow provided SG I . gpd Plan: Date fi ^ )'7 ' % 9 Number of sheets _ Z Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 1,500 }4) O `S_T - H ZO D BOX L% ) ZO �5qo L�e. The undersigned agrees to install the above described Individual SewageDisposal System in,accordance with the provisions of TITLE 5 and; further agrees to not to place,the system m operation until a Certificate of Compliance has been issued by the Board of Health. Signed, �� Date ^w Inspections No.£j�P . COMMONWEALTH OF MASSACHUSETTS �r ��J� Board of Health, , MA. CERTIFICATE OF COMPLIANCE Descriptionof Work: ❑ Individual Component(s) lS Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ), Upgraded bandoned ( ). by. E>tC�t t4x�..-i v O di atrQ has been installed, 1acro e with the ro%a�o ns o l0 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to application No. / (_r ., dated �7 f Approved Design Flow t7 5 (gpd) Installer J "'" 3 Cy'C,:m) Cx4 t o t Designer. < j Inspector: f �./° _ Date.: The issuance of this permit shall not be construed as a gua 5 tee that the: system will function as designed: No. t�©C'iC7 J FEE 00. COMMONWEALTH Of MASSACHUSETTS ... G Board of Health, 4a. ry,' a gAV" , , MA. DISPOSAL SYSTEM CONS RUCTIO VER IIT Permission is hereby granted to Construct('-' Repair( Upgrade) Abandon( ) an individual sewage disposal system at T`ct V 1 t, tr J as described in the application. for Disposal System Construction Permit No(/ f _ �� , dated' Provided: Construction shall be completed wirhix e years of the date of this pe In All.local condi 'ons must be met. 7 Fnrm1255 Rev. 5196: A.M. Sultrin Co. Charlestown, MA Date '� � Board of Health