95 Application & Permit 2005)Cation
I
r/f'2
ap/Parcel# %S.S'/G is 5/.r-- ,e04/✓
,t# NO/ZTWA' ///7-'- M/45S
staller's Name
ddress
elephone
/1 �i/ in—ta.. // 9 ...5�
_ I' P a r Y_ ! aifrim
e of Building /2e5 /I,q ��J/j ,'1&, 1£ Lot Size
elling-No.of Bedrooms cO 4/OO 114 Aid) p/S/0
Tvpe of Building S/4/6/f F/9/7% /[-� No of persons
FE n
'COMMONWEALTH OF MASSACHUSETTS
Board of Health,A/0/2171i9/1744•Q MA.
ON FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Owner's Name GC%/t6s//9/77 /74
Address DD/ - 4;02)N ///Lt Si,9/E
eL.I9
Telephone#�44 e'/O/S 36S )
Designer's Name� //, �f/77 / res
r(
ddress - Ur, f "7a /eCe
elephone#
ter Fixtures F/%//- //4-1r
sign Flow(min required) j/(. -%.3'7 Zprl Calculated design flow 195 Design flow provided
Revision Dare
C
ix/S /sq.ft.
Garbage grinder(420
Showers y).Cafeteria (44)
/Mk./L 76 02 CarN,Irnber ofsheets /
[C (5-F/917 SVCTE'J W /CM_ uJM ,5-771 TeX >S I//[57a
seripdon of Soil(s) ti Ef' /2-11-19-01-/ ,�/ /U5—
S/.E/2 e9tfl fl 7<
A/At(/J L /cV//(J67 5-5 1.4
?/O C R/1 /5: ZS/
7 gpd
Dare
1 Evaluator Form No.
/1 Name of Soil FlvaluaroibLJ ✓ Dare of Esaluation
ISCRIPTION OF REPAIRS OR ALTERATIONS
ie undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
bled q Sr Date
specnon
COMMONWEALTH OF MASSACHUSETTS
_ / 'rTr""
Board of Health, r / �/ r 7 AL4'
� �
CERTIFICATE Of COMPLIANCE
scnpt o of Work �dtvidual Component(s) ❑Complete System km ssrN<- i Lie
undersigned hereby xifs that e Sewage Disposal S sem C i rutted ( Repaired , Upq dyd ( ndoned ( )
I»'I>w4»-dia 1�/ -7hr-c4 Pli27rI a !J -, Ain
-- y.1/ , 4 r ct1 rte- - -1 ,A-r4/1/-4-0,1 57a Cr
iD
s been stalled in -'ordance with the prosb s of 310 CMR 15 00 (Title 5) and rl vaned design plans/as-built plans relating to
plic Lion N<y S- // dated f/j ly/ �S . Apprised DesiS Flow/_(gpd)
smiler 17%( l F t )1Ci 1 16
,gner: 1'/(LN4/1%Jt, . rli ft' Inspector: . r /5. I)
re issuance of this permit shall not be construed as a guarantee that the system will function as designed.'
Orr
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Z/ 1.171-7 1-7∎11/'O�% 1Lt
DISPOSAL SYSTEM t ONSTRLCTION PERMIT
FEE J
ermission is hereby granted t ; Construct( ) Repair((/) Upgrade( ) Abandon( ) an individual sewage disposal system
ys /4- Le2-t2 ly [f4-/{ ,/ — v. t d t%i sip - j I'Li /IL as described in the application for
rsposal System Construction Permit No.a ts(i- /( dated1 )2/Cli.3 .
rovided: Construction shall be completed within three vears of the date of this permit Allslocal conditions must be met.
m,1255 Rev 996 AM.swrn co eosor_MA Date 5 I t I 0 5 Board of Health //✓f'0 / `1/' 1 Yiteitt