124 Septic Application & Permit 2002 Appticadt
COMMON11/LALTII of mASSACHUSLTTS
Board of Health, - /J6' 114101 Q MA
APPLICATION FOR DISPOSAL SYSTLI CONSTRUCTION PLRMI !
T
FEE
Location / V Cra% Pofr'ry O
Owners Name U9L34C,4 �Ms7/f C
C
Type of Building
Dwelling-No.of Bedrooms
Other-Type of Building No of persons
Other Fixtures
Design Flow (m�c. required) Li gpd Calculated design flow
Plan: Date VZ1�G7 + /� Number of sheets t{
Title /. "Z)S F M 1<I X+,� 140AI
Description of Soil(s) / (* 55 i- 1 IC 4
3
Soil Evaluator Form Nu.
DESCRIPTION OF REPAIRS ORALTERATIONS
Lot Sir Ol17S0 / sq.
grinder(A/
Shown ( ),Cafeteria ( )
32)C) Design flow in
Recision Date
ided 14/12 gpd
Name of Soil Evaluator 4 Gun 5 ` Dar
ct-t �Lia• J
widuait tir'eW 3-1 :le AA_
Evaluation f//IDOL
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree to not to place the system in operation until a Certificate of Co pliance has been issued by the Board of Health.
Signed ." () I 4 /i ,t I A Date - 1/)
Inspections
COMMONWEALTH 01= MASSACIll'SLTTS
Board of Health, /L'/-f B Jh 24/ M4.
CERTFICATE OE COMPLIANCE
FEE
Description of Work: ❑Individual Component(s) cLegiciplete System
The undersigned hereby certify that the Sewage Disposal System; Consume ted ( ),Repaired () Upgraded ( I ba d il (
bv: i3i /1 c.I Cr r print '//
at /may 012 5 /----/-74/, A -
has been installed in accordance with the p sions oES10 CMR 15.00 Oath.51 and the ear-osetl design ph in as-built plans relating to
application No. "'` C `` dated C '- I -."Approved Design Flow !/ (gpd)
Installer �_ /
Designer • /r Inepen _. t;lt� 1 '-.._Dare / /- 5'e-
' .
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OE MASS/11_110AITS
Board o f Health /1.4 W 7114.7-11-&4731% u .
DISPOSAL SYSTEM LONSTRLICTI'ON PERMIT
FEE
Permission is hereby granted to; Constrru&i( )/Repair Upgrade( ) Abandon( ) an individual sewage disposal system
at ! a V /./ G1 /
Disposal System Consmiction Ferinit`No.
Provided: Construction shall be completed within three years of the date of this permit.
J.c -
Board of Health
dated ' "1/2.-=•—•
Form 1255 Bea 995 AM.Sulkin Co Boston.MA
Date /
r<_
as described in the application for
lll
sal conditions must be met.
/
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