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COMMONWFALT14 OF MASSACHUSETTS )j
Board of Health,�T , MA.
APPLICATION
FOP DISPOSAL SYSTEM CONSTRUCTION CTIO PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 16j,13 tvv i5r1v,!S %�
Owner's Name /Zoo-'a� /
Map/Parcel#
�V -7
Address .20 �L r j I I �'-d-v4
Lot#
Telephone# 7 (/'
Installer's Name El I J S
C
Designer's Name JLorn %)0/ Ci C-9,0, I 1 `I G
Address a3 1 ) �e f
/, c
Address (J, 0 e 3 (�Sg- 1A1
Telephone# Sct "-a60-6,_2'3
7
Telephone# "7 `, S-- % 7
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date 9`.Z7"1 Number of sheets Revision Date
Title 5174=-1 'rZ - _3!' -%�T�' L'�T 7 -se
Description of Soil (s) 4%/'P %� -511714y ' r/ X-) '/ 1 . 9-
Soil
Soil Evaluator Form No. Name of Soil Evaluator Date of
DESCRIPTION OF REPAIRS OR ALTERATIONS—,
IS'Zr i y6^Z 5�-�C'T�C_ 721?�4k_ %-:✓10eK
�!"�f� �/ J✓LC B��/�1i� 6"��j'% �4�✓ �I.��� C3 J/'�� d�l����%�
The undersigned agrees to install the above described,Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no 1'a a the system e t].L til a Certificate of Compliance bee 's d by the Board of Health.
Signed �/ (r' 1� /Y °' Date
,Inspections
No. COMMONWEALTH OF MASSAC14IJSETTS FEE
Board of Health, MA.
ILT
CERTIFICA Of COMPLIANCE 71�' Z."?
Description of Work: ❑ Individual Component(s) UiKComplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (�; Abandoned ( )
by: L U S E3�O.S
at S %i(.//L / // 1 %%% S /6CJ
has been -installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Jr- ` �'7�� , dated Approved Design Flow (gpd)
Installer 46A;� j .
�s
Designer: %ZV/Y/5�'LIt% �. �I'A�/l L/%j�nspector: Date:
The issuance of this permit shall not be construed as a guarantee tha the system will function as designed.
No. 0 ----- -- E -z. �. S axDo J FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, ftAM &J t- , MA.
DISPOSAL SYSTEM CONSTRUCTIO PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade,.( Abandon( ) an individual sewage disposal system
at :503 W'/ as described in the application for
Disposal System Construction Permit No. , dated �i �' 9 .
Provided: Construction shall be completed within three years of the date of this permit. All local co
nditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ��� O Board of Health