428 application for Disposal System 2018 1 .
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Type of Building 2E Sty/t-ki ri/7t HO nit Lot Size C,/ /sr/4/En,.ft.
Dwelling-No.ofBedrooms 0 .e.E///.loty e.L.,.nitd/Sp0S L Garbage grinder (yES
Other-Type of Building o 7AJ t.E /Cictfl/t y No.of persons Showers (a Cafeteria(A)c,
Other Fixtures FULL fjni T W/n'�yi4111-11-4-.0 efa/d/G/L a n,c4c C
Design Flow (min,required)/10 K Y. t /4 /Calculated design flow 4/oo Design flow provided CO gpd
Plan: Datef/P.CIL /9.20/4 Number of sheets / Revision Date y�
Title Sic/or/4 sysS�" A/1e1i, i/✓z ( 7l7.ulL. P/fr6oa .-e'/rLn-ecAtAeA/
Description of Soil(s)
Soil Evaluator Form No. '"—' Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS AS/)oSnc z- ea xis:/v1 o v Ep
Set 771--tf S n_AspircTlo.v wioxr ,s//"/ao/B
The undersi ed ares o instalthe above described Individual Sexage Disposal System in accordance with the provisions of TITLE 5 and
further agre to asht t tice tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed X 4 -i/ Date C —j4— I D
Inspections
Na 2Y)/ — FF.E%:'/t/1 cc
COMMONWEALTH,OE ' ASS CIIUSETTS
Board of Health, ' ' a _ /• I •. ,MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) U Complete System
The undersigned her y certify hat Ole Sewaige Disposal System: Constructed ( ),Repaired ,Upgraded( ),Abandoned ( )
by: -..-1—€71)• -.1.. c Elite ( r 4-1-.P --T-7.-,s+
at 4 ' 1,,e5.-pr 4-- e Unr
has been installed in accordance with the�pr visa is�of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. dated )
1 ' . Approved Design Flow 6Ai/1 (gpd)
Installer —[7s1 r—r P pp /
Designee—epi ,r Inspector: C - -. _i Date: b/QR 5?
The issuance of thishpermit shall not be construed as a guarantee that the system will function as designed. ///
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No. A.%% / FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health. /G/1/7//Cr.r,i.- �4//MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ,) Repair(j(f Upgrade( ) Abandon( ) an individual sewage disposal system
at '/l' (//, (ee, k/ if-,a- /// y ' ,: t r as described in the application for
Disposal System Construction Permit No. ,dated C 11/4.17//,;-(
.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev 5196 AM amus Co.Chas * Date 2 n/� Board of Health - -
/ /