7 Septic Application & Permit FEF >O. J�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, No r 4,,,,P'Jr MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Abandon( G e 1 t System ❑Individual Components
Application for a Permit to Gousouu(yf Aepair( I Upgrade( ( 1 - pe 19
Location r ii ,
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Owner's Name TF‘i-co -a -1—
E J�
tv7 2
7
Map/Parcel# 3o -
y
Address _
a
Loth -j
Telephone# Lu3 s2- 7 Gib)(--I..�
Installer's Name MAC JA
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Designer's Name JAN to A
.,G■ A
Address _ -- _
Address a a - _ a ..
Telephone# 4_8( Z m 1 cIIL
Telephone# wZ 7,251.7__
Type of Building Dwelling-No.of Bedrooms /-f
Other-Type of Building
Other Fixtures_c A.A n ke
Design Flow (min.required) _ _ _
Plan: Date 3 —2I- i0
Title /Z
e `Pi6/6J�i Z/J -'
Description of Soil(s) fro�m7
Soil Evaluator Form No.
F o- J. ii_•r
1/
No.of person.
0 gpd Calculated design flow ?'l%
Number of sheets
Lot Size Az 3 tJ -7 sq.ft.
Garbage grinder
Showers ( I.Cafeteria ( )
Design flow provided 4ce#0 gpd
Revision Date 3-24 -26 2
-O/
1,9.-ejn (c4- 6.-1 ,4/Ji,
Name of Soil Evaluator it T/6nri?5d4/ Date of Evaluation 04 4 5/7*
/a_5
DESCRIPTION OF REPAIRS ORALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to 9pt to place system in operatiot until a Certificate of Compliance has been issued by the Board of Health.
Signed ) Date 3 - . _
Inspections
No.
COMMONWEALTH OF MASSACHUSETTS
FEE
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: D Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by:
at
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. dated Approved Design Flow (gpd)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, L'Ilr u,s, Pki-, ALA.
DISPOSAL SYSTEM CONSIRUCTION PERMIT
FEE
Permission is hereby granted to; Construct()f Repair( ) Upgrade( ) Abandon( )an individual sewage disposal system
at 1 ,..,. 1 I `'' ''I
Disposal System Construction Permit No. 1^. P , dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. MI local conditions must be met.
f_. u^•Form 1255 Rev 5.96 AM.swkn Co.Sharslwi MA Date . 1' Board of Health li/,'iRcId/ V