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Home My WebLink AboutApp-Permit-ComplianceNo. o t / PEE �✓ CI©MMONW� AiTH OF MAS -SAG �USETTS ,L 1j �L¢�'i BocFrloflL'T"�f+ ,.MA. �U APPLICATION ,FOR DIM, �, STR11CUON PE-IRMIT Application fora Permit to Consu-uct( ) Repair( ) Upgrad(�Abandon( ) - )2 Complete System ❑ Individual Components Location W ._{ y)dfy." rIitGPl 9 L- 94 Owner's Name [; a&p1fd Map/Parcel# (0 020 Address pp (,j a$ gag/ Lot# Telephone# Li / 7-5s 1 7 Y6 6 Installer's Name 1:-:1 i's ,(i}oTJ),.t e -7'f C- Designer's Name fze-n-,/Q CIdI//yC Address 8,.3 )-fnJr�i/Lc,% Address /-3013-4 �,-SF 4,es,- u'% Telephone# 3 Telephone# SaF 7 7S 5 70C Type of Building Lot Size sq. ft. Dwelling -No. of Bedrooms 3 Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design Bow provided :i Z- gpd Plan: Date 4L'd' L . A2C, % Number of sheets f Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. L_ Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS ,s -f' P & ''l- L 0-S/ ZP 1 Date of Evaluation The undersigned a re s to install the abovedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees oUt lace/e • t / p t on until a Certificate of Compliance has been issued by the Board of Health. Signed t/ Date V / No. G� / _.� f i PEE �t:J `�� COMMONWEALTH OF M�ASSCI�IUSETTS (� 17 r� Board of Health, � <- � ;M, C U. /'fie , MA. CURTIEIChE OF COMPLIANCE Description of Work: ❑ Individual Component(s) -Complete System The undersigned hereb certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) by: rf // S /'C l S at tui" ,nvJt•4in e -n ,,, �,.,�., moi. f_ re Q,rc.� has Jaen installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and it, a„pproved design plans/as-built plans relating to application No., (`% /�, dated'"'/ _.or Approved Design Flow (gpd) Installer Designer (k� t f,) .� t"rytl' t' �r( Inspector: y'.,./^;a� - [✓ ;r t 1 k..:- Date: ✓ F�'�... e -i / The issuance off this permit shall not be construed as a guafantee that due system will function as designed. �^ No. -I' PEE COMMONWEALTH OF MASSACHUSETTS f'< Board of Health, 'r • c„w-) h MA. V DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to; Construct( ) epatr( ) Upgraded) Abandon( ) an individual sewage disposal system ate/r't>'7 r)`�'` ” y t h G Ui �''} , tr,s described in the application for Disposal System Construction Permit No. 0%'"/ 77- , dated g Provided: Construction shall be completed within -the voaathe date of this permit. All local conditions trust be met. Form 1255 Rev. 5196 A.M. Sulkln Co. Boston, MA Date �-��Board of Health t 4 f