521 Septic Permit 2005 o.
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COMMONWLALTI1 OF MASSACHUS£IIS
Board of Health. Vii.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to' Construct( ) Repair( Upgrade( Abandon( ) an individual sewage disposal system
as described in the application for
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Disposal System Construction Permit No.O"35---32 dated
Provided: Construction shall be completed within rye years of the date of this-(ppee/rrmmii�tyc�'�•�Vl local conditions must be met.
Form 1255 Rev 5/96 AM Sulkin Co Boston.MA Date D 5 Board of Health V ''" ° a llit W1
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COMMON'W'E:\ITII OF MASSAC/ITUSETTS
Board of Health, 4/0%2<17/4rij /Galt.
FEE 5 .W
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PLICATION POR DISPL)SAL SYSTEM CONSTRUCTION PERMIT
m Tto Construct 7 Repay tipgra(IX) el6rndonO - Complete System 7lvdividual Components
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Owner's Name /204 4,US //
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b�ap/Parcel#�r�i /J 0/3&tu.o R
Address ,5a/ 0
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Telephone#
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Lot#
Installer's Name --F.,. or
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Designers Name
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Address
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address
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Telephone# e!!3 -yG 7- 9 e a
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Telephone
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Type of Building 14 S//'JJ4.-N 77/1-6_ /Jt Lot Size %D nom-ell.ft.
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Dwelling-No.of Bedrooms (7/-/7./f"//700k/'��� 4/�% visoof x6 Garbage grinder(4,6
Other-Type of Building l� ,c - % No.of persons 4, Showers a Cafeteria/$
Other Fixtures /%(.l_ g/14r w Alt ear
Design Flow (min.required) /10 tS X l Silated design flow 4 25- Design flow provided �� gpd
Plan: Date) .P.T//% 9__ JC
Number of sheets ,./Reviisiion Date
Title (ifrA77L SV 7X-re "-Pilo/C/ et /7"/`�S 0 ..521 4OOL p
Description of Soil(s) fee, At r7-' ' `''� Re
Soil Evaluator Form No. /7 Name of Soil Evaluator Date of Evaluation /l///G i
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a eGg to n9t to plac th em in operation until a Certificate of Compliance has been issued by the Board of Health. '
Signed! ail-h CX% t1 t Date /o(i ?l'a '
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