41 Application & Permit 2003 (447—":"49-/ FFL II
� INAL S31y01.1
COMMONWEALTH :D[ MASSACRUSLTTS
Board of Health, Her .upird ' MA'
APPLICATION OR POSA YSF 14_ONSTRIICTION BERN,
-a Permit to ConstntctO Repair Upg ade Aband r( ) - ❑Complete System 7lndrndwllC mporpt5
nn
parcel#
1 prvCt La .
6 us1272,/I TBK /A -
MA _ 3G, , LcT ZJ 3
Designers Name
le rs Name /CgQL'S ,fl�f Wont
iIt Address
hoe }7i Lam% Telephone
ne# ?�`�Sbi(, —
Building �SI
g-No.of Bedrooms 3 UT eh)
Type of Building
rixovcs
Flow (min.required) tl0 gpd
yam t2l 6103 Numberofsi
0k'c 51-ctn elpatr
?don of Soil(s) ([O 95 1„ 6R.JD
•aluator Forma No. Name of Soil Evaluator
Owners Name
Address
Telcph011
a.nS
leM 6ln.
W/ Spruce L4.
5810 - 5637
4/w /JJe.f5 15
AtA
1i3 -3Z.3 -S7 Si —I
` Iot Sae 4411 3`1 risk sq.ft
B6tecrEcIS15J per CI Garbage grinder (11/4/
No.of persons Showers( ),Cafeteria (
Calculated design ) an y
Revision Date
S I lit) •
Design flow provided_SSA_gpd
RIPTION OF REPAIRS OR ALTERATIONS
4, (Alt 9.5C Date of Evaluation -12/2/03
114441 L, r Ici
r agrees rsees to agrees to install the the above described 1^�a Certificate of Compliance has beenrssued by the Board of Health.
5 and
s a to not lace the- to
Date
c dons
COMMONWLAUIIT (iT M,1SS: I IIUSLTTS
CLRTTLTCATL ()L COMPTTANrk
VL1:
ation of Work: 7 Individual Component(s) D Complete System
ideisign(gi hereby certify that the Sewage Dispo ,1 System: (:on struciedO,Repaired (Xipptidt it 11donMt7
tu (stalled l accordance with the prrititin s c t 310 CMR 1100 (Title.) and du approved desig plane/as-built plans relating to
It1011 No 7 / /' S dated n/it 91.(49 i 5 - 'Approved Design Flow y/ (gpol
Inspector Due.
;mane oAllis permit shall not be construed as a guarantee that the system will function as designed.
FEL
COMMONWEALTH 01: MASSACHUSETTS
Board of Health, )l/ r d //)Zii tL4
DISPOSAL SYSTEM CONSTR ICTION PLRMTT
ssion is hereby granted to; Construct( ) Repair(EK CpgradeV) Abandon( ) an individual sewage cl isposal system
/n/ / . (c -. —Ft-, as described Ti i the application for
sal System Construction Peron No. 9- : .dated/ / /�/ 3 .
led: Construction shall be completed within three veins of the date of this permit. All local conditions must be met.
Rev 5:96 AM.sWkn Co.Boson.MA Dated)tt(I/tt3 Board of Health14,7/j �' �'