531 Application & Permit 2002 ORIGINAL
COMMONWEALTH OE MASSACHUSETTS
Board of Health, NaarUPA&P7i1
MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PEW
ation[or a Permit to Construct( Repair(y'1,'pgnde(e7 bandon() - CfC:view System ❑Individual
anon
a�a
Owner's Name LEONAtaP �A ltht(pt/ S
,/Parcel#
,3 Q2491
Address 53( W[&ik. p
.ict FCxr Aicrikorki
201
Telephone#
*3 se� /]� Z6Z,
tiler's Name
Designer's Name
/�,� G/ers5 t as
revs
Address
e Irl'IOrgOacl PA
phone#
Telephone#
‘i(3 -3L3 •st sq.
d Building
ng-No.of Bedrooms
-Type of Building No. of person
Fixtures
I Flow (min. re aired) II° gpd Calculated design flow 330 Design flow provided 383 gpd
Date 6 to AV Number of sheets Revision Date
Sr$S 5,143\C QQfv 5 SA)
ption of Soi (s) t-4z°!i' 'j.. S v + L. e)64 . ,,,, ,,
valuator Form No. Name of Soil Evaluator£ 4 II,,
. `5-5 Date of Evaluation 5)342-
KOSi(�[�wiC9_
l7,
Int Size :3524641- sq.ft.
Garbage grinder(M
Showers( ),Cafeteria ( )
RIPTION OF REPAIRS ORALTERATIONS G`)4A(Ik-+C ftJ 3 393 -
rdersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
r agrees not to place tem in operation until a Certificate of Compliance has been issued by the Board of Health.
li=„to Date i'7f4/C% Z
bons
ii Y--
No. FEE / L
COMMONWEALTH OF MASSACHUSETTS
N��
Board of Health, t7 it-ma c/74/;, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ,lndividual Component(s) ❑Complete System
The ugders�ugd hereby-cgrtify thane Sewage Disppsal System; Constructed O,Repaired ( Upgraded OAbandoned ( )
i �JV ✓// (a c^(`T7� Cam-.e
at j 9 / �K 6 WI-(l Ht1,J
has been nstalled ii} ccor5ionce with e proc¢� ;stuns yf�CMR 15.00 (Tide 5) and the approved design plans/as-built plans'clad
application Ny /(/T date /,'l .7/b- ' I-App oved Design Flow (gpd)
Installer rte. ' 6" 7 2.+mti'7L Ar '')
Designer: rir O N IA/ / s / Inspector: G e- Du , 4.-Date: 7/C/-' 3•The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ill-C. F FEE 5>0
COMMONWEALTH OF MASSACHUSETTS
r
Board of Health, tOP ( 4444' �'F , MA.
/
DISPOSAL SYSTEM C®NST UCTIUA PLRMIT
Permission is herebygranted ; Consauctt((;) Repair(rpgrade( ) .Abandon( ) an individual sewage disposal sy
at -5/ h i�d'/ Q/Fk.O : ± as described in the applicatio
Disposal System Construction PermiENo. //17-1:ett,dated 6 //l/e D—- -
Provided: Construction shall be completed within three years of the date of t Jpp/eri'ni?AA'l�pjlocal� dons must be n
Faun 1255 tress Mros AM.$Akin Co.Boston,MA Date 7 G�Board of Health t+—a Ja" " e �' /.4-"-