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Board of Health,1146 ROUTE 28 MA.
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-1 lApplication for a Permit to Construct( ) Repair(° -Upgrade() Abandon() - ❑ v/ Complete System dividual Components
Location(OS
CQ L
Owner's Name
Map/Parcel#
7 - 6 1
Address
Lot#
Telephone#
Installer's Name
AST&a-r,>
Designer's Name t 2t
Address
�yC� p
Address 5
Telephone#
Telephone#
Type of Building S/N61-z EA PAIL i Lot Size I l� (0 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
' Design Flow (min. required) 33 U gpd Calculated design flow 330 Design flow provided 1-32 G gpd
Plan: Date i - Z`t - Cr7 Number of sheets �� Revision Date
Title
Description of Soil(s) 56S SOI t- L0-6
s='I` Soil Evaluator Form No. Name of Soil EvaluatorW5 Mcit--XDate of Evaluation MAY 31 07
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 FALUP 57N�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree o o eerie system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �/1 Date 6-1S"d--7
a Inspections -,% -F
2— FEE 'V' (/ C/
COMMONWEA T14 Of MASSAC14USETTS ml" (, r
Board ofHealth, YCl n�2i;,-" IvrA.
CERTIFICATE OF COMPLIANCE
Description of Work: A Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: B/ ara72 - i XMd MZ—Z M
at 63 C�/9�d,�I�/ L / /Z.12
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to
application No. d / 2 ated tf r 20 -O 7 . Approved Design Flow (gpd)
Installer PAcYC12
? n
Designer: Inspector: 46 LO& Date:
The issuance of this permit shall of be construed as a guarantee that the system will function as designed.
No. 0 7-2,; 2-- (,' < f FEE %V• l/G./
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at &-3� C4A-• 5"A;40 "jc as described in the application for
Disposal System Construction Permit No. 6') -1-,2';4 dated - -c)7
Provided: Construction shall be completed within th��r�.15of the date of this permit., 11 local conditions must be met.
Form Rev. A.M. Sulkin Co. Boston, MA Date � O9r Board_of Heallt/h 7