599 Septic Application 2000 NWEALTH OF MASSACHUSETTS
Board of Health,4OfLTNq�M Tfb N MA
ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
to Construct(bRepair( ) Upgrade( ) Abandon( - ❑Complete System ❑Individual Components
FEE 75
ation
CoLES MEADOW QO
p/Parcel#
aller's Name r_,,A9j.r
f �x.4kvA I t WJ
Tres
Owner's Nam
Address is- Vt 5 _MW(
Telephone# 4t3 _ 427 d
Designer's NameT
M I A
- NK Q.S
phone# (4-9) 54.9 -351
!f Building 51 t)6-LC Pctl'Av(A/
ag-No.of Bedrooms 4-
-'Type of Building
Fixtures
Flow (min. required) 4-1-0 gpd Calculated design flow
)ate [g-U-oI -+tip - Design flow provided Q3
Number of sheets
Revision Date
Telephone#
2.1 - 5241
No of persons
Lot Size ea 4-ACRa S ��
Garbage grinder H-
SShowers C r ee'e )
Le\'Y.4 00( Goo Syr n - Ler C-
1100 of Soils) 5jol�l.Ay Av-y Sa ((++
£�NL- •f'ULM
luator Form No Name of Soil Evaluator Q R(.aR 4t,p5e
gpd
IPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation I/-IS -DO
ersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
Trees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
vu
Date ?�
q3
COMMONWEALTH OF MASSACHUSETTS
, IAA
CERTIFICATE OF CO(IPLIANCE
n of Work; ❑Individual Component(s) ❑Complete System
'signed hereby certify that the Sewage Disposal System, Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
FFE
nstalled in accordance with the provisions of 810 CMR 15.00 (Title 5) and the approved design plans/as-built plans rela
t No. dated . Approved Design Flow
(gpd)
l U5
g to