HomeMy WebLinkAboutPermit 02-537 No C3 7 FEE
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COMMONWLALTII I I.'AfIIL BUTS
Board of Health, A.
1146 ROUTE 2 EALM DEPT.
SO. YARMOU
APPLICATION FOR DISPOSAL SYSTEM DO 'LION PERMIT
Application for a Permit to Construct( ) Repairp Upgrade( Abandon( ) - ❑Complete System J Individual Components
Location ter-,5 Owner's NamecAf /�
Map/Parcel# I c( /1-1v Address �`�
Lot# py Telephone#
Installer's Name �i�J) j y�, INC, Designer's Name
Address ( y , `� ,I n( 5 ' Address
Telephone# v A 3 ` �1 r�+ I J Telephone#
Type of Building Lot Size sq.ft.
Dwelling-No.of Bedrooms Garbage grinder( )
Other-Type of Building No.of persons Showers( ),Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS D . I 0)4 din / S • S'.4-e
-0-d/ - b c7s re-F
The ui a igned agre to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth # e Itct le e m in operation until a Certificate of Compliance has been issued by the Board of Health.
SignedV, t Date
Inspections
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J FEE T-U
No /G.1 M It 1 8 !C)
COMMONWEALTH OF MASSACHUSETTS
G
Board of Health, , MA.
0. - APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repa+) Upgrade( ) Abandon( ) - ❑Complete System 0 Individual Components
Location e 61_ 6-7- ,5, /c r c�✓.e Owner's Name)1 61_" 1 4 D—Li
Map/Parcel# I q' /y-la Address
Lot# Telephone# -
Installer's Namepy V1 J� 1 � 1 'ws ,
.������ Designer's Name
"t
Address sbX i, /01
, l4 NI)3 Address
• g Telephone# !� a S 2 Telephone#
Type of Building Lot Size sq.ft.
Dwelling-No.of Bedrooms Garbage grinder( )
Other-Type of Building No.of persons Showers ( ),Cafeteria( )
Other Fixtures r
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
.ti J , \
DESCRIPTION OF REPAIRS OR ALTERATIONS D D . Y ,U ) d I "'— S •, Arum, c,4 'C
►, $-d! c 0 G75I ,(- J
The i ed afire to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furthil
er 1 ce e m in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed\ JV 1 IJ Date
Inspections
FEE S"
No oa - 37 COMMONWEA II OF MASSACHUSETTS
Board of Health, , MA. 7 1'' 0)(
CERTIFICATE OF COMPLIANCE __.. U 1A IX —
Description of Work: ' Individual Component(s) ❑Complete System
The un signlend,hereby cer' tha the Sewage Disposal Syste ; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by: L.-V v i ` AtrtY51 i N e . _
at 4- 1VE
— �� f _ 5. &. 0c0 5 1/4-h
has been installed in accordance with the pr visi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.O 'S 1/7j , dated l t c'L .Approved Design Flow (gpd)
Installer k 112 (((( �-- D I / n� Jive
Designer: 1 Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ° -S 37
FEE ,. ;
COMMONWEALTH OF MASSACHUSETTS ; o
Board of Health, 1 J f 1 '-M U U t"1 MA. '0'
DISPOSAL SYSTEM CONSTRUCTION PERMIT X
‹,4.-- O"6 Syt1Q---N .
Permission is hereby granted to; Construct( ) Repair 96 Upgrade( ) Abandon( ) an individual sewage disposal system
at t21'3'1 c5f I()j('E1 y 1 yg - i 'J ,(/ -7 as described in the application for
Disposal System Construction Permit No. °d -S 3 7,dated 1 o`/i 3/o.Z '/
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 A .Sulkin Co.Boston,MA Date 1 d`11)/0 ZBoard of Health ?:`)