486 Application & Permit 1998 No. EE 36 '
COMMONWEALTH�®T MASSACHUSETTS
ifBoard of Health,1.1) -A {MTh , MA.
A•r APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
�t for a Permit to Construct( )) R�eeppyairC��rUpgrade( ) Abandon( ) Complete System ❑Individual Components
Hf 6 {,)i%/bT1< 2p Owner's Name poi.IG/or.1t s7n 'y I'It�it P
Location �
Address Q� �/ _
Map/Parcel# " ' ,y�dESj�(Z . Ol� �
V1 Loth Telephone# p �
iInstallers Name Designer's Nam 1st I 6hoNfi S /Qs
ddress Address Qd file j fr u [J kirreI
Telephone# Telephonee# (443 ) CCCV? t ) ) 1
Sf.U6l �i4yyl Lot Size�ty ki.-9-&'<
T of 1 tLy
Dwelling° 3 Garbage grinder
Dwelling-No.of Bedrooms //
Other-'Type of Building No.of persons V Showers (v)!°`"
Other Fixtures
Design Flow (min.required) • gpd Calculated design flow Design flow provided 9a-
Number of sheets Revision Date
Title tn. Dr r1YV1 *b E
Soil Ev [ t of Soil ) t • <J<s»7.f'� _
Soil Evaluator Form `•.
Name of Soil Evaluator —o IBC_ Date of Evaluation 1.17l..V. .
DESCRIPTION OF REPAIRS OR AITERATIONS 1M;_= • 16_47, 60 es '' tleTr'P
51=7.vt D1pos9-c cy /RA"
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE
further agree to not to?lace a systeration until a Certificate of Compliance has been issued by the Board of Health.
Sign eaJbu u a Dat J . I , I S98
Inspections
7-7k
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /lnadlr)r4 MA.
CERTIFICATE OF COMPLIANCE
:ription of Work: ❑Individual Component(s) ❑Complete System
undersigned hereby certify that the Sewage Disposal System: Constructed O,Repaired (4f Upgraded O,Abandoned ( )
£4 VA/ // coN= reeve r:VN, ap
ykG SYavr-7T,f to/90
been i 31 stalled in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans built plans relating to
ticanon No. 27-re _ dated 6-27-78 Approved Design Flow 57z (gpd)
alter LA✓&"UY re,Vr:+7o/'-",cN /et-J.'
igner.
Pruri/Y 7/B4 /N5 Inspector: Den 5 re
("W / Date: /e!.-349 -72
issuance of this permit shall not be construed as a guarantee that the system will function as designed.
/Y //t/%5- FEE ) 22
COMMONWEALTH OF MASSACHUSETTS
Board of Health, At 44 f'a % MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
R' air U de( ) Abandon( ) an individual sewage disposal system
'mission is hereby granted to; Construct( ) �(( pSm
¥ 'h S7/v r i /"✓ as described in the application for
c
sposal System Consu a tion Permit No. C7%— / ' dated 7I/ 7 X/
ovtded: Construction shall be completed within three years of the date of this qrl . £11or�dii//d�(i iyfnust be met.
1255 Rev 5 99 AM.Sulk Co.Boston MA Date S Board of Health {/(� ,/�i/\ V�"02.--
FFE J�