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No. -d',1Z.1-ki"-.Y� `'"O Cft�t. -nZ DL6-066 ®"`�-/ FGE Wy7•v(J6
MMONWEALTI-I OF MASSACHUSETTS ci+
Board lfHealth, \ MA.
)PI LIGATION FOR DISPOSAL' SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Rcpair( ) Upgrade(J(`AbandonO - Lal Complete System ❑ Individual Components
Location Z &CEEZE7 1?01Nt ft'1'i
Owner's Name
I4LC AJOS$IWet
Map/Parcel# 63q, �-�-j
Address S'z""7 —
Lot#
Telephone#
Installer's Name ,SPRIeMmmv &-f6il-V^-71/N
Designer's Name
SPIAL i PES(Al
Address 1$ 5(?L-- r W." "'qet-lLrl
Address l`'1
CLAy s•T, M/ L'gNu
Telephone# ne (f 2,5TZ5
Telephone#
766 p,S44
Type of Building ')t4l NS Lot Size b• 17 —4- it
Dwelling -No. of Bedrooms 4- Garbage grinder ( )
Other -Type of Building _ No. of persons Showers O, Cafeteria ( )
Other Fixtures / �.
Design Flow (min. required)Lf c> gpd Calculated design flow Design flow provided LM- '7 gpd
Plan: Date 17113110 ? L fNumberofshects Z Revision Date solkshe't l2/'/�/8
Title
Description ofSoil(s) _
Soil Evaluator Form No,
Name of Soil Evaluator jeowe Date of Evaluation
DESCRIPTION OFRLPAIR.SORALTERATIONS ISS o(ST t fl- uz /()00 J'4C PUAP t/174(l%M
¢t•?v D -B(* -+ SAS
The un s •ees to install the • described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
ford k Mees ton to place th •tem in peration until a �Certificate of e plianchas been issued by die Board of Health.
'� \Signed `Date 1"
No. (' 612 t l) -._C. °..A...ti`F � W FEE is--" .
COMMONWEALTH OR MASSACHUSETTS
A`" . ✓&r° �."a G,3"��� 4 °spa C" ""' 9
f t
Board ofHealth, 8,07 1A c iR`74 _, MA
$1AE-2A-002627
CERTIFICATE SOF COMPLIANCI oK 7K►9� o �►
Description of Work: El Individual Component(s) ❑"Complete System a I I I
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),cUpgraded\1 17 O, A�handoned ( )
by: ,
at `"7 �' i''; E C , it rpt,
has been instalhe in ace r lance with dhe rovhsums oep. 10 CMR 1.5.00 (Title 5) and (lie approved design plans/as-buiiCplans relating to
application No. •` t$"../ dated w--' /i r'.A . Approved Design Flow'r"i d . ?e(gpd)
Ty
_
Installer i �<4f") �, et-�A-4 �+"' SJ"'i:�.f� � ,-.
(�7 zz
Designer:— Inspector: Date: Date: 4
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
DC„.,h_..UYl .�.���1�� d'r.. `aS'�f�,k°.-6�'1�-@0�l FEE,t�"�d,p1
T1 tw' COMMONWEALTH OF MASSACHUSETTS
Board of Health, 7A yY 00"x1 a MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) UpgradeAbandon( ) an individual sewage disposal system
at f as described in the application for
Disposal System Construction Permit No. F” / (. , dated
Provided: Construction shall be completed within dix6years of dii date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. 9uikin Co. Clade%arvn,,MA Date i a `' `� ' Board of Health