850 Applications & Permits THE CO ONWEALTH OF MASSACHUSETTS
/1) MASSACHUSETTS
Certificate of Compliance
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arda z�ty
THIS IS TO CERTIF . that the In-site Sc age D wsal System installed or epaired;ieplaceu ( ) on`a+
OD • _G ^ r7Gh /A. .a__/ . ' a .—._ Ow E.
at /rli ,_>e >�a a I ° n'�=` " 4 �"has been constructed in
accordance with t provi ons of Title 5 and the for Disposal System Coast r lion 'ermit No. 4 R Y—%A 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
Di OF Of NUM
- RIGINAL tA.1
COMMONWEALTH OF MASSACHUSET TS
APPLICATION FOR DISPOSAL SYSTEM CONS UCTION PERM
vpli n for a Permit to Construct( ) Repair(✓f Opgrade( Abandun() - omplete System ]Individual Com
type of Building
]welling-No.of Bedrooms
)Iher-Type of Building No. of persons
idler Fixtures
Reslcie..IIt
A2
Design Flow (min.required)
Iam Date lin/04
Fide 5SP19C 5754(n■
)(ascription of Soil(s)
Evaluator Form No.
I.nt Size it 9t-L-, sq.ft.
Garbage grinder 75.
Showers( ),Cafeteria ( )
UO gpd Calculated design (low 1%0 (Lit)jcsign flow provided stiq gpd
Number of sheets f Revision Date
L or afcu Cep ;r P-44
Name of Soil Evaluator 4, ("less Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Altai 5. T4.JIG 1- / 7R61 rM
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
Further agreenit not o laaccee the s em in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed !✓/ �-�/ Date 9-la
Inspections
kk'5u r A
Owners Name
i F u
•.+:.�f"
5 eel
4Z /37-
81$ O1
Address
.t
Fi)
-
Telephone#
Installer's Name
• , Al 1 J
b, i ,g.' i
�W
'.:•"LL. • r
r .d ..a'
i • 07
.
'Telephone
53
Telephone#
type of Building
]welling-No.of Bedrooms
)Iher-Type of Building No. of persons
idler Fixtures
Reslcie..IIt
A2
Design Flow (min.required)
Iam Date lin/04
Fide 5SP19C 5754(n■
)(ascription of Soil(s)
Evaluator Form No.
I.nt Size it 9t-L-, sq.ft.
Garbage grinder 75.
Showers( ),Cafeteria ( )
UO gpd Calculated design (low 1%0 (Lit)jcsign flow provided stiq gpd
Number of sheets f Revision Date
L or afcu Cep ;r P-44
Name of Soil Evaluator 4, ("less Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Altai 5. T4.JIG 1- / 7R61 rM
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
Further agreenit not o laaccee the s em in eration until a Certificate of Compliance has been issued by the Board of Health.
Signed !✓/ �-�/ Date 9-la
Inspections
Ja;w`)( FEF .12)-7
COMMONWEALTH Of iv, ' TACIT ISFTTS
Board of health, '�f / ; n. f•�'_
CffTIFICATf Of COMP IP IAN'CF
Description of Work: ❑Individual Component(s) 7 Complete System
The under cd here.y- ri f that rh, Sewage Di.osal System: Constructed I ). • paired raded () . bandoned ( )
by SL_,rte. Lemereet
at AISISTIE )-7S.Ate
ha:been a lI I in ordance anal the proc.ie is of 10 CMR 15.00 (Td 5 ) and the a picot('design plans/as-built ph -is lati tg it
application h t j1 _ dated ore D sign Flow 11N1) � //q h.
1 ll
r er _� ii �Ll u/ L "e. _•�. iu e
UJ
Designer N B Inspector Date: ti_�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.-2F11
CN
COMMON\ L\tTFI OF MASSA I US-KITS ' .ef
Board of Health, ,41U f�t figri sj . MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repaira/Upgrade(L ' Abandon( ) an individual sewage disposal system
i
at � W6 / Jvi l2T-d✓J IJ — XJ/ti ! r
` }t'f�ll J�X as described in dry application for
Disposal System Construction Permit No. -v✓/ � ,dated)7/.4/1. 2 /4/
Provided: Construction shall be completed wit in three years of the date of this Der mit. All local conditions must be met.
Fern 1255 Rev 5: MI A uM n Ca.Boston.MA Date
m �h �� / 4 Board of Health 7 y/Y
l '