HomeMy WebLinkAboutPermit 03-410 No. 0 1/0 )5 V'LCK-Ce i '- f /A f v / . RG / FEE Or 0
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_ COMMONWEAWL 1
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Board of Health, 1146 ROUTE 28 , MA.
APPLICATION FOR DISPOSit?. ` PSI tl CTION PERMIT
Application for a Permit to Construct( ) Repair64 Upgrade(V) Abandon( ) - A Comp a System ❑Individu C9mpynents
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Location..2.D Nioff olz yr Owner's Namel) ',-KcLC1,,Q-i. _y.\,,�
Map/Parcel# 1 q au Address���� O
Lot# I Telephone# /3o t da�g
Installer's Nameep. y�1 C 4oes L�—i c Designer's Name�i)a �d. Eq .
Address �7 S �` �Ma ,l�Q t,x,�� C.1A'A O,wc,'Y( Address CC i eA.C,TNA 001, 1.t`tcvs (—
Telephone# 5 $_ 38s- 43 Telephone# 50%.8 We;_4s(9 l
Type of Building U /L/ /V/et...Pi i ."' Lot Size sq.ft.
Dwelling-No.of Bedrooms ,r / Garbage grinder ( )
Other-Type of Building /L92 z J f /(f/ �/1� No._ of persons Showers ( ),Cafeteria ( )
Other Fixtures �jt_C- 7``zi`f / xce T' GG[- SiS/ c•-90,60,
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date 8-tt-C)3 Number of sheets \ Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTI N qF REPAIRS OR ALTERATIONS a2Q_ Q\.c -,,
J,L j,/v 3 ! --1 S -t l 6 0 y GAL.
The under '. ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
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further a: $1:. s t the t in operation until a Certificate of o fiance has been issued by the Board of Health.
Signed i Date
Inspections
No. 15 _410 445'42'Aar-- ("0 C �� / FEE 91-- f;�' Z/COMWEALTH OF MASSACIIUSIT S '-�/ /49` 2t 5-
Board of Health, p , MA.
y 4Q,�;.n h am , dva ce7 >
�E� TILL�1TL OF COMPLIANCE /f, � / - etiti(
Description of Work: ❑Individual Component(s) ®Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (. 'Upgraded ( ),Abandoned ( )
by: Yap. cc-C2 % TiC
at U
has been installed i acco dannyce with the provisions o 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
t� -7/(o application No. , dated //-- 7'e . Approved Design Flow — (gpd)
Installer'.\.(Y1_ Gje.-6-0cCors, =hc.
Designer: '(. Q Cock Eel.. Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as design-ed.
f ,No.- / 1/0 ,- - 61-:aCe thAe7/,/UV Q/ S C J' �. !/
FEE p
COMMONWEALTH Of MASSACUSETTS» �U �zG�
Board of Health, , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Nec Upgrade(V) Abandon( ) - 0 Comp a System ❑Individu C m nents
Location,2g J( T @ u o u t Owner's Name--in�t " -c�c V Q�' .=-Y
Map/Parcel# \✓ )j"q l/ o Address '� D H u6
Loth Telephone# �,,S V1,a 0 0
Installer's Name �- «,(,- e,s ►3C Designer's NameCick_4r 4 Ld E r`�
Address- X 77 S' b� n,,,, M� GaloYI Address 5L I.,exc.t.c1 -- clack, bccwsik r'
Telephone# 5-U ' .�3 - g ci 3 Telephone# C/A-8 962- /8(.c t
Type of Building 0.O/L iti e _ice[ 7 l .. Lot Size sq.ft.
Dwelling-No.of Bedrooms Garbage grinder( )
/1
Other-Type of Building 92 �� 49kifL�d No.of persons Showers ( ),Cafeteria ( )
Other Fixtures �x/ / i 1 C• 7,# .6 zk S/ CGdt/Dv-- S7
Design Flow(min.required) gpd Calculated design flow Design flow provided gpd
e
Plan: Date 6,7•f't- ,3 ; f toNutttbtr of shee/ts, Revision Date
Title Y, «.
Description o oil(s) 0/
Soil Evaluator Fo/m No. Name of Soil Evaluator if . -e" Date of Evaluation
' DESCRIPTIp14 REPAIRS OR ALTERATIONS � ' '1 c�,n `'"'
Li-Pic?3 Tw44 S t) g(iY asiC
The unde ' ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a rttrehe, t m operation until a Certificate of o fiance has been issued by the Board ofHealth.
1 ,L DateSigned
' Inspections
I , ,
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FEE OD
No. 3 4/ COMMO W[ALTLH OF MASSACII1JSLTTS tirk /
Board of Health, '(LiZ cr y-IL h , MA. /
y .2en 6zt/ iC 7P-07>
CERTIFICATE OF COMPLIANCE ,,/ I o i is 70-K ic--
Description of Work: ❑Individual Component(s) 51 Complete System
The undersigned hereby certify thatlthe Sewage Disposal System; Constructed ( ),Repaired (N(Upgraded ( ),Abandoned ()
at 5O [V1 i �34-Ine-6 OAVr
has been installed i accda/jnce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No.L2or
-"7./[/ , dated //- 9-e', . Approved Design Flow (gpd)
Installer q•1t\.C11 Lp.-'�cc4c.kr rS 3-.C.
Designer: C.a p(e e:,t',A .,-Nt. Inspector: • Date: '
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. -
No. C/2 /1 V 19K/i/ - ~- FEE66-V (/C./
COMMONWEALTII OF MASSACIIUSETTS r/c6
',2 i�--
Board of Health, u t7 m r�L>J.h , MA.y
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Vr Upgrade( ) Abandon( ) an individual sewage disposal system
at 2 S(J U 1W 5H0r Qgj V1 as described in the application for
Disposal System Construction Permit No. t 3 1/d,dated //`3`z1 3
/�j� S
Provided: Construction shall be completed within airP1s Pars of the date of this per it. All local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date//`/ V 3 Board of Health ZV -V
FINAL INSPECTION
,/ clADDRESS
INSTALLER:
NEW REPAIR
DATE: Ira /C!, d
TIME : (77 Pi/9
NOTES :