36 Applications & Permits tlicalion
FEE 743
COMMONWEALTH OF MASSACHUSETTS
Board of Health, klarCriskivsp I 313 ivm.
ON FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
istruct(l Repair( ) Upgrade( ) Abandon( ) - U Complete System O Individual Components
to of Building
4elling-No.of Bedrooms
her-Type of Building No.of persons 6 Showers( Cafeteria ()
her Fixtures
SING-LE FerekvoL� LLorsie 31" u10 sq-ft
No g�RY F PSI e5rit
ALL i>�gwu!«N-9
sign Flow (min,required) gpd Calculated design flow
Number o�f heets
J;st-�Y• c\1Fch-
m. Date
scripdon of Sod(s
it E.aluarnr Form No-
)
5 QiSQo t
1_ lei R 5 A b W
Name of Soil Evaluator
SCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided b V 7°
Revision Date —2U
gpd
Evahtatio
C, w- 51 11 5,t4 n-y ci 2
2.75/j
re undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther agrees to not m in operation undl a Certificate of Compliance has been issued by the Board of Health.
gncd V CI Date -1—I
spections
.nation SKr aPaSA) ft\EInOOW '•
OwnersName V/ -E'1(j1...)
cNl -pitSGS
dap/Pmcel#
Address jlt,
.J RD -iv Vf/r
.or# LJ i i l
Telephone# (4 12
4-2,:i
6� '/
nstaller'sName l �yp C,O_A-0-,�
Designer's Nam�Ak
i,IUJPS
p
/L5
Iddress RD Oast.,/?
5(1 JIl'f�tJ✓` \. !s% Ice/" Wf�/wi
Address /M. Ni'OOM
Pe ."'-t
,y
telephone# l A i--0 5-12- 70 a i
Telephone# 4
1
2
—S-2%/
to of Building
4elling-No.of Bedrooms
her-Type of Building No.of persons 6 Showers( Cafeteria ()
her Fixtures
SING-LE FerekvoL� LLorsie 31" u10 sq-ft
No g�RY F PSI e5rit
ALL i>�gwu!«N-9
sign Flow (min,required) gpd Calculated design flow
Number o�f heets
J;st-�Y• c\1Fch-
m. Date
scripdon of Sod(s
it E.aluarnr Form No-
)
5 QiSQo t
1_ lei R 5 A b W
Name of Soil Evaluator
SCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided b V 7°
Revision Date —2U
gpd
Evahtatio
C, w- 51 11 5,t4 n-y ci 2
2.75/j
re undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther agrees to not m in operation undl a Certificate of Compliance has been issued by the Board of Health.
gncd V CI Date -1—I
spections
-
49 tea . i 1441 a
N<,- COMMONWEALTH OF MASSACHUSETTS FEE
Board of Health, , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) U Complete System
The undersigned hereby certify that the Sewage Disposal System: Constructed ( ),Repaired ( ). Upgraded ( ),Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans rel;
application No. , dared Apprmed Design Flow (gpd)
Installer
Desigoen inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. 7/
FEE 5
COMMONWEALTH OF MASSACHUSETTS
■
Board of Health, I ( .�.,i ' , MA.
DISPOSAL SYSTEM COMTRLtiCTION PERMIT
Permission is hereby gran red to; ConstructO Repair( ) Upgrade( ) Abandon( ) an indi rid ual sewage d isposa]
# <^
at /, 0 � /� . r)V P 2 e 1 j�rN�/ �1P qCf r�to S as described in rite appllcaa
Disposa- System Conslr tic ti on Permit No. v"-��-fix .dated
Pmnde5 Con U- :don shall be eomple red within three yens of the date of this pit All local cc ndillo
PcSOn.Mr Date 7/0 c/Bee,
ltr_ .
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
FEE 65-
P, 6/0
ation far !TSpusat System Construction Permit
reby made for a Permit to Construct (✓for Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No.
LOT 44- II
. SCAtcREl(yAl Pt
Owner's Name,Address and Tel.No. e41y 52,-1
Too CCLL.t)2A goal
135, $oIL r 7S a 12A
Installer's Name,Address.and TeI.No.
eellura Corn roc-- rOn 1170
581-ftt
jf,Ex,„'tv,ct✓h etc'n �d- g I c
ielt&-hti na atm MA_ 0102-7
Designer's Name,Addres and el No.I
'AiJ terGisNIS is C5770-5z-q/
')o Mni011 AGUE. RP
w 5-509,WwidRAJ, NAA
Type of Building:
Dwelling No. of Bedrooms
Other Type of Building
Other Fixtures
Design Flow 6 79. 37--
5-30 -01
Plan Date
Title
4-
Garbage Grinder(
No per Persons el- Showers(✓f Gait.. ia-E—T
A -01
gallons per day.
L Number of sheets
Calculated daily flow
°a Revision Date .S 30"01
666 gallons
1fALA
Description of Soil 5tb FLAW
11-,AP 64I4. PvA-W/\
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has b sdhys B Health.
Signed
t!®
Date L5 3�" 0/
Application Approved by Date
Application Disapproved for the following reasons
Permit No Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( )or repaired/replaced( )on
by for
at has been constructed in
accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated
Use of this system is conditioned on compliance with the provisions set forth below:
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed. This
Certificate expires on
DATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS `f///
No. (I- 13 / 2 t'f 44r 'II// MASSACHUSETTS FEE
pispnsal Sgstem Construction Permit
Permission is hereby granted to qtr .i
to construct(v )or repair( )an On-site Sewage System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
DATE / 1 / 4 Approved by
FORM 1255 Pee M95 A M SuumN co.•BOSTON MA