Loading...
HomeMy WebLinkAboutApp-Permit-Compliance�e � -- s(ttu•�. / 8�;�d✓arm ���' ��=-s >/-� C S�rSJri�� �crx�e� 5,�,;� ✓,� No. FEE COMO. IASSACI�USETTS ` ..M Ur ,t L lro�c:, �C�n 6,-)g Board of Health, 1146 ROUTE 28 MA. APPLICATION FOR DISPOSAL SN���1 �I �����IJ� TI�Di� P��RMIT � ? �/01� yv3 Application fora Permit to Consu-uct( ) Repair( ) Upgrad . ) Abandon ( ) - ❑ Complete System/5—Individual Components Location 1'k C((� Owner's Nmne �-r.Q(1TC Map/Parcel# Aa - &4 2i ci ce. Z Address 12— Coh-e od-{ ni * Lotti Telehone# r 309-3G309-36-2- P - 1HLf Installer's Name Designer's Name �Ut��d Address I�-' C 1. Address R3 GIn St I .N1 Telephone# Telephone# 50 'Z_ Type of Building 1 -r-') Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design Flow (min. requir d)) gpd Calculated dkkesign flow Design flow provided /'i�c% gPd Plan: Date &' (H 1 V Number of sheets 1 Revision Date Title-Tiilt-� Sire—Mon Description of Soil (s) Soil Evaluator Form No. Name of Soil EvaluatolA f n l fl ( 0't C4_ Date of Evaluation 14 0 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 ag/(rAqto not to pla a the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed l lC..lJf). J1d g�© -/51 1 ,DDaate 6 Inspections S' '�a"l `d / �d/ Q?�/ �G9�✓S �'' No. � ITL, .r!.... PLL' �.� 7 , (.i(.�✓ COMMONWEALTH OF (MASSACHUSETTS Board of Health, C. f /& /""'�,r"MA. CERTIFICATE OF COMPLIANCE /, �",),y /J e� Description of Work: ,, dIlmlividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (� Upgraded ( ), Abandoned ( ) by: 9"b (I`$r Ei f osinI_ i/)fi ICl at (1, �f r:rV,(iti) has been installed in-t'.,acc 7} nce with the pKovisio is of 3 CMR 15.00 (Title 5) and die . >proved design plans/as-built plans relating to application No. `-' f �.-.,. dated Yom` ' /` " (`-1� Approved Design Flow (gpd) �;^ ,,e� Installer I '( `"t 1 s'J .<'°'aY'C.��/'` Cit. ; - , / r"`r i.. t.'i d / ,'"�,.;' i.r t_,fkF� e "t':a$.=.d" Date: �°�^, .. ^,�:. "l,/ Designer: fl\ I -1 (flf-i • Inspector: 7° "*d u The issuance of this permit shall not he construed as a guarantee that the system will function as designed. No. /)f _ 7 j f `� ✓ d . % FEE COM Mi ONWEALTII OF (MASSACHUSETTS t " ' i �` 3 tr Board of Health, ('- £ l3l '. a , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(v') Upgrade( ) Abandon( ) an individual sewage disposal system �yym at (R," �.. f -f" � lt~'E-,C i �''l'I; �1 � (16 (Y if as described in the application for Disposal System Construction Permit No. i7 L_ ,dated ✓ (/ P date Provided: Construction shall be completed within,thu, years of the date of this permit./All local conditions must be met. Board of Health Form 1255 Rev. 5/96 A.M. SUINin Co. Boston, MA Date ' f i J /`rte