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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ig OTi r l�f --d� �Z �+ � � � —� / � � FEE b�S; Oa r 1 VVV COMM® TSI Of MASSACHUSETTS C X5010 Board of Health, Y49&Q Vn4 , MA. A PLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT A plication for a Permit to Construct( ) Repair( ) Upgrade (K Abandon( ) - ❑ Complete System (Individual Components Location / r" el t H Owner's Name Map/Parcel# ' :' 6 Address Lot# 7-- 5' Telephone# 6-.>- Installer's Name U Designer's Name o . Address V �� ��/� Address Telephone# (� fj '- Telephone# Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ No. of persons Lot Size / �� � sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 3,3 t7 gpd Calculated design flow Design flow provided I? S-5 gpd Plan: Date 4-1 ?-aj Number of sheets l Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. T Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS � a CA l � �! —4/ s- / -r " 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 p e the sys m m ration until a Certificate o^f� Compliance has/been issued by the Board of Health. Signed ��+/ _ Date / ` 11 Inspections No. .l'lrv�� FEE ! S' co COMMON�I,T14 OF MASSAC SETTS Q Board of Health, YAAmo Ltn , MA. CERTIFICATE Of COMPLIANCE Description of Work: ll7 Individual Component(s) ❑ Complete System The undersigned hereby certify teat the Sew a„Disposal System- Constructed ( ), Repaired ( ), Upgraded (abandonedfe ( ) by: at % -11 i has been installed' ' �a�cordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to p ica Sn . -j”, dated fl .Approved Design Flow (gpd) Installer -e f J Designer: 6., Inspector: Date: The issuance of this permit shall not be construed as a guaryltee that the system will function as designed. AW �C r -00 No. ��� � ©� �-�'(^"� FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, 9A007-9 , MA. DISPOSAL SYSTEM'CONSTRUCTION PERMIT Permission is hereby granted to; Construct( at / �' r(,e /_,. f Upgrade(�O Abandon( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No. { , dated Provided: Construction shall be compl'ete`d within threegs of the date of this pe it. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown, MA Date 7 –—' BoardMealth 4?6I -s44 it 4i: f /'�' srsx , ts� rmru A10-