41 Septic Application & Permit 2005 Jc4 - �uy L PhL 7i ,
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COMMONWEALTH a �i>rt'SsPcIllsITTSGi� ?�
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Board oflleatth, �G4 k16 ■n � 9^ Md. .I o •�i 33
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(i0 Repair( ) Upgrade( Abandon( ) - Q Complete System ❑Individual Comp eats
Local :I7< &C S5/2471 Pd
Ownet/aie Lq /r %/GfyPr1 . 1)-
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Map/Pal(el# 2S _-7)2
Address( eoSS436 i 1
Lai#
Telephone# 0�/3 L. 7 - 093p !-Lk.
Installer's Name
M�1LC Mor7,ursi�l
Designer's Name I eC-
/� s. , Gv�/sr
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T- ephone# , ,L Al" Q • - till',Y -
Tel phone to _ S
bpe of Building
)welling-Na.of Bedrooms
Other-Type of Building
Other Fixtures
Design Flow (min required) /
No.of persons
Lot Size £J1 (c.(i( ±
Garbage grinder Au)
Showers ( ),Cafeteria ( )
gpd Calculated design flow 330
Design flow provided S/� gpd
Plan: Date i 2 / 3-3 / QL( Number of sheets Recision Date
Tide SPp S TVA ° S ' S/v /0/6n
Description of Soil(s)r-, e /G S 5 s[
Soil E■aluator Form No. Name of Soil FA Anatol %q L</e r is
Date of E■aluation //123/0"
DESCRIPTION OF REPAIRSORALTERABONS IV $JS (/ I .)ew iySfen-,
The undersigned agrees to instal the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
4- Signed Signed Date r
t I
Inspection � 'f'2/U(a - �` A/Wa-1,-2,4e-'7Gtir '--)
'COMMONWEALTH IfONWEaLTH (1W MASS,ICFIUSFIIS
Board of Health, 1:. / t (//-istl/7;, / MA.
CERTIFICATE OF COMPLIANCE
FEE
Description of Work: ❑Individual Component(s) LIComplete System /g lit / .'/N',
The undersigned hereby certify that he Sewage Disposal System: Constructed ( ),Repaired O,Upgraded ( ),Abandoned ( )
/
at t7
has been installed in accordance with the provisions of 310 CMR 15.00 (Title ) and the approved design plans
application No.-. / dated / / /App oved Design Flow J45/ (gpd)
r
Installer —
Inspector 6 4/ �i 54: 414/+4 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, //hr-knu///Jail MA.
DISPOSAL SYSTEM CONSTRUCTION HERMIT
built plans relating to
Permission is hereby granted to; Constructel Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
f
at i '/ c'3yf ,%l/�li )1y/*'/�. r /" 'J7�;;J <,:rC t7/,/ d" iN as described in the application for
Disposal System Construction Permit No. -- -, / , dated / //'L_
Provided: Construction shall be completed within three years of the date of this permit. Allflocal conditions must be met.
Forth 1255 Rev.5,96 A M.Sukn Ca Boston.MA Date )' / Z/C }Board of Health 7 /a 0.1.,1 /2ll/4-