56 Septic Application & Permit 2004 COMMONAYE LT1I f)L MASSVI II'SETTS
Brand f Health, tJorh1HN.451cm-) , MA.
1CVT1ON LOP DISPOSAL SYSTLN LONSTRUCTION ILR i1T
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Addn�ss 5L C(2oS S ciH)lh RGii(P
Lot# S 6
Telephoned (s-r3) s`6 C - (,, I ?
Insrner's Name
Desibmry N.nne I,,orhy C. i r&iJN)6 RS
Address
Address9 Ro-&J6Sik A.�N
u Muu"tnGvL-
Telepnone#
telephoners (4-I J) 52"i - 529l
Type of Building
Dwelling No. o YE Bedrooms L I E 5,
Other-Tspe of Ritgditg
Other Fituu es
SiNGEE. GA,w,;Y
lot sq_�ft.
(garbage grinder P4eri
Showees (y-6afeertr[
No of pm Nom (r)
Design Flow (min. required) 3 30 gpd Caleulared de+ign flow 4°l S Dr,dgn flow pimisled S5 G gpd
Plan. Date Da C. 3 2,oCA- Ntn„het of shees Retriou Date s. .k) )A
Dde G2-pi‘ Sy s'tZ—LA Des - �IerA7cfZ Lewc r+,.1/4,6 c s
Desetipdou of Si (s) 5/c — S C
Soil 1A alnamr Font]No. Name of Soil Eultimo c Afti6>/Al.t)are of Es.duadon {A-4-014-
re
DESCRIPTION OF REPAIRS OR AI TERM IONS 12epcAO E 5v BSA;1/44- A(z D S2 a66- OISpc5AL
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he undersigned agrees to install the above described Individual Sewage Disposal Sjstem in ai`6u�pgwith the provisions of TITLF.5 and
further agreed to not t place the sss ie in operation until a Cern ate of pliance has been issued by the Board of Health.
Signed . /� L[vtr`"� ) te �� /0 r
Inspections
No2ez 4 «�
COMMONWEAllill I)I 'L\SS;\Cl USFITS
Bonot of Health.,42127.4702-, MA.
CL1tTILiC, IL OL COMPLIANCE
nent s le System
Description of Work: ❑Individual Component(s) m p
The t u lrslgned Beret y�} rtift that the Sewuit Do_p_o.yal SN'Steln j Copst F IC tedOltt 'rc. rod r�,Y/).Abandon ed
earillaitibrarlEtWEIMISISMWr
10 Cfido u) and the approled design plans/as-built plans relating to
D 'g yluw4_(gPril
FEE .,L).: al
has been t talle it e will
application . ' dated
1nst Ile:u" ( � y A
Desgoe _ nY U m
.pertor /Yl�h
The issuance of this permit shallaot be construed as a guarantee that the system will function as designed.
NU,ZISbY - �8
P
C\iR 1
\pproy
COMMON 1 'LAI fIl O1 yI SSAI
Board of Health./--21.0-c= K/ /r--�
DISPOSAL SYSTEM CONSTRUCT]
flUSLTTS
DDate:
ON PLITh..IIT
! L
A_I
FEE -2U /{/
Permission is hereby granted tre Conor t( )„Repair(i Upgrade( j ardon( ) a nnidual seW.agedisposelsystem
at _/;---k / /t,tca-o / ""'^ - ' -qq�"�����` —'"i" "."(d 'k J�K � as described in the application for
Disposal System Construction Permit No.L-FXa(Y•lI S .datedi4k( Zr 20
Provided: Construction shall he completed within three years of the date of this $�- .it. AI local conditions must be met.
Form 1255 Rev 595 A.M.swan oeton.MA ate .YL/ 265V Board of Health