50 Septic Application Permit & Compliance 1pplica
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FEE 50
COMMONWEALTH OF MASSACijUSETTS
Board of Health, /1/0C//g'mffiUvbL4.
%APPTICC TION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
or a Permit to Construct Repair(lf h'pgrade( ) Abandon( ) - ❑Complete System Individual Components
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Address /ed• e Or 'ry 9
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Ma /Parcel# �o,t�//g/Y)'7V,u ,-/4
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Lot#
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Telephone# 5737 ai 90
Installer's Name
Designer's Name)//A�) cJ1nie-U70
Address l/b U //C/I,el lea/
Address
Telephone#
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}pe of Building
Dwelling-No. of Bedrooms Garbage grinderno
Other-Type of Building No.of persons ^ Showers i),Cafeteria WO
Other Fixtures p /✓
Design Flow (min.required)7S�C gpd Calculated design flow 2C e Design Bow provided_,�3/_3 CJ gpd
Plan: Date tAJ 4 �/ Number of sheets OW, Revision Date Q�/f
Title_�JgP%a4CE g/ro./%L ( /iyI /./.1/n/ ,C4 a l 7 W., nA[,
Description of Soil(s) c AeT%flc-4, 0/ /WA*
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GCFS/--0„na Q Lot Size sq.ft.
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Soil Evaluator Form No. // Name of Soil Evaluator tCJL S/C//e Date of Evaluation
DESCRIPI ION OF REPAIRS ORALTERATIONS
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The undersigned.d a o' tall e . ve described Individual Sewage Disposssjjjlll System in accordance with the provisions of TITLE 5 and
further agrees t r t t. pla W� in operation until a Certificate of Co{u cJ4g{§een issued by the Board of Health.
Signed I Date 4// f/ z
Inspections
No.
COMMONWEALTH OF N SSAI HUShTTS
Board of Healt
CEDTWICA E OF CONIPL ANCE
Description of Work: ikie IK vidual Component(s) 7 Complete System
The uu 1 si d he cloy certify .'at the Sewage Disposal System; Conn'uc ne
red ( ),Repaired ( ), Upgraded ( ),Abandod
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... .au. r - i ,! (/ -i s el-t, _c I
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has been I lled ith aigorii ice wit h die pro si�f' 310 CMR 15.00 (Ti tle 5) and the appromd design.'plan
application No. /7 % ,flared q/'Ii/Iy . Approved Design Flow 7,0 (gpd)
Installer
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Designer: (: I IL - Inspector: (/
The issuance of this permit shall not be construed as a guarantee that the syst m
No
Date:
ill function as designed.
I. OMMONWEAILTH OF N , SSAC FIUSETTS
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DISPOSAL SYSTEM CONSIRITCIIONI 'PERMIT
nit plans relating to
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Permission is he by gra edto ConstructiRepair( ) Upgrade( Abandon( ) an individual sewage disposal system
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at ��/ `t ^— �� � ii,,a., ) if(/ t � as described in the application for
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Disposal System Cr nsu'ISUOn Permit No. �_q/ dated �`/ i
Provided: Construction shall be completed within,three years of the date of this p9r n AII)o<a)±ontd must be met.
Date i Vtftoard of Health C/`�� % €74