HomeMy WebLinkAboutApp-Permit-ComplianceNo. / �U / ..L�� ��Cf !t.. J� ' 4�'✓/"i,./� /`moi �V
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COMMON EALTII Of wMASSACIIUSETTS , � � � �; (� 6' 1
Board of Herrllh, - /L7A.-'b -4n 15 40wll�
Ahhi ICATI'ON EOR DISPOSAI.51'�TL�I��i� �t�i,�5�lhl�f ��I�C91�' PERMIT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( O Complete System Individual Components
Location
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Owner's Name Iq evil
Map/Parcel# G°' '
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Address
Lot# X9ax>J%
%'.v a� /e%z
Telephone#
Installer's Name
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Designer's Name S'vn /g'f
Address
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Address rs. a
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Telephone#- ji•,:rff eeF9,?
Telephonetk (}'' �y',�-s -a/ % i
Type of Building 4L- C Lot Size
Dwelling - No. of Bedrooms 3
Other -Type of Building No. of per
sq. ft.
Garbage grinder ( )
Showers ( ),Cafeteria( )
Other Fixtures
Design Flow (min. re aired) gild Calculated design flow if �o Design Flow provided o gpd
Plan: Date lzFI � Number of slicers Revision Date
Title I�
Description of Soil(s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS ORALTERATIONS
Name of Soil Eval
4,6"- t Sr
Date of Evaluation
The undersigned agrees to install thp-plin?yedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not the -t fn in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed .` —t Date f- aT
COMMONWEALTH
OF MASSACHUSETTS
Boai-d ofllea111a, G� „roil PL/L""/ ° _, P'L4.
CERTIFICATE OF COMIDLIANCE
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Description of Work: L�=Individual Cnnponent(s) ❑Complete System 7
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The undersiy tied,iereby • AiCy if at the -Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (Abandoned ( )
by: QAC wGf"�LJLA
at 7 f 5` tA�rd'fil L -J e
has been installed in_accorda ice with the provis ons 0f310 CMR 15.00 (Title 5) andtl e proved design plans/as-built plans relating to
application No. •.)`9 , ! clatecl %� G' Approved Design Flow ' ✓ /(g�pd) /,�
Installer py....,, -1 ,r._, a'^'<, G''✓✓P1Ty {.CI} 'r' fV'r'1 �,� p: G'/>vW/ /�J/��6'
Designer: d.^"G°irk! �°t. '. 6�"� Inspector: t -.,i.41 (V',6 Date: % j' �`7" c°✓
The issuance of this permit shall not be construed as a guarantee di4t the system will function as designed.
No. Ld •"'," L _.... �l`^� / F'°t`P! S')1%•`.:� FCL
COMMONWEALTH OF MASSACHUSETTS � {
Board oflleallh, �,d %)/
DISPOSAL SYSTEM CONSTRUCTION PERMIT (/
Permission is hereby granted to; Construct( ) jRepaii ) U/pgracle,(,C} Abandon( ) an individual sewage disposal system
at �64 �✓' 15/ /id��d?a�1L V/ 14 as described in the application for
C
Disposal System Construction Permit No. (%7� �f,� clatecl
Provided: Construction shall be completed within th-reee-}ears of the date of this/Pet)mi):�All local condidops most be met.
Form 1255 Rev. 5/96 AM. Sulkin Co. Boston, MA Date �� �� Board of Health