235 Application Disposal System 2018 47
Telephone# TelePhone# ttv2/2n£TT �
s/j c/9 /..e/ i Vf/3 617 707 v
Type of Building ,e4c-5/12/ NY//3L 1/- 44 t Lot Size gr.,5 i sq.ft.
Dwelling-No.of Bedrooms 4,3r£p/700s4-11 ,L0 a/spas/t /-,I)/r . Garbage grinder G4/O
Other-Type of Building ries//C/&oc-E- A•prn/L 9' No.of persons e9 Showers (t,Cafeteria
Other Fixtures fOat'/cL //z0 FULL- "gni/-
Design Flow(min.required) UG k V gpd Calculated design flow 9 9-G Design flow provided A 5Z d
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Plan: Date A1en"/L /Z 20/00 Number of sheets / Revision Date
Title 5.0C try. S 's-1 %,-Ad ,(2/j/64.1 /tel it ✓ZIc£.P/I /7/+d,G.C,C
Description of Soil(s) Slg+fr 4-Mir/YE 0 2-.35- UC..SC /v//g/J-/JOLC/ /24
Soil Evaluator Form No. '// Name of Soil Evaluator LUTs//t z(// ate of Evaluation 9--//eVeedi
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DESCRIPTION OF REPAIRS OR ALTERATIONS ,$S/j'.7,,r/a% 5-y5/ -�--/'l•7 /2-'L fin/4 y.4 L
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees not to pl ee the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Sign* , OCC Date Gy/?'..20/e-.
Inspections
No.-XX. - Jj FEE li.(.,'
COMMONWEALTH OF MASSACHUSETTS
Board of Health, �','ir. 1 +t,. ,, Hi':-Lr,J , MA.
lir
CERTIFICATE OF COMPLIANCE❑ COp
Description of Work: ,Individual Component(s) Complete System
The undersigned hereby certify that t re Sewage Disposal System; Constructed 24.Repaired)l,Upgraded ( ),Abandoned ( )
by: -7: K Le C
at 935 0,1 P3 /LI e,.-krILA I -Fuc A
has been installed in�ecoodance with die provisions of 310 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
xI3-r
applicationllrNo. [dated /{118�) . Approved Design Flow it 56 (gpd)
Installer l� //
L I VOl ,
Designer: '-Ou — i C r-y°.- bur T�[nspector. - Date:
The issuance of this permit shaB not be construed as a guarantee that the system will function as designed.
.
Ni,. c/C/lrf.. FEE U I',6.)
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 4,t -ry r,. .,,� .i
t.) , AM. P �
1
DISPOSAL SYSTEM CONSTRUCTION PERMIT LrdLI LI hL L U L_.i1
Permission is hereby granted to; Construct( ) Repair(/) Upgrade( ) Abandon( )an individual sewage disposal system
at „ L( , ) ( r,l,-. , / ,,',, A G u , r ''c, ---1 as described in the application for
Disposal System Construction Permit No.2O I Q-5 ,datedL4 1 r'(I ;;- -
Provided: Construction shall be completed within three years of the date of this permit. All localditions must be met.
Form 1255 Rev 5/98 9M.smv�e Co.ChaesoxtMA Date )2511(. Board of Health . �`'�
(