808 Septic Application & Permit 2008 COMMON1 IAITI OF MASSACITI'SRTTS
I{)N FOR IDISPOSAL SYSTEM CONSTRUCTION PERMIT
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Location /a" /Z Fa
I Map/Pareel# Og /3 /J//S //F/ )//D
Lot# 027 /4 2/1/OU 44/LS
/. a/• (10/ /0,t/
S 6t srsr ////77/-(g
Owner's Name
I Installer's Name
I Address
Telephone#
Type of Building
Dwelling-No.of Bedrooms
OtherType of Building
led design P
Uisgn flow
provided A4. Sf
d
Other Fixtures //(2/-5- U .04'
L ,Design Flow (min lei-mired) Numhr of sheets Revision Date
Address
oaf' o/275F /
rt.� j3 89' Bsi-
Designer's Name /661 / /C /1„/
Address 5/33 P--()/7./ ,57-
Telephone# --- — — - O
/0/72Z I of Size sq.ft.
/10//6t}7 76 /L F/O.2__ Garbage grinder yrs
No.of persons_8_Showersde.Cafeteria (Aj(/
k- 2E/G//C
Plan: Date
Title s-"IC/177(
Description of Soils)
Soil Esaluator Form No.
Date of Evaluation
Name of Soil Evaluarur_
DESCRIPTION OF RF//RO / LT IONS
772 7( 7//.0/6/2"/ TL�F� 107-
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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 to,ot to place the systetn in operation until a Certificate of Compliance issued by the Board of Health.
Signed F -
Inspections
No. C7
CQM\IQNtWL\LIII OF 'MASSACHUSETTS
Bonrd of Health, , MA.
CERTIFICATE OF COMPLIANCE
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Description oT worx: �u•W�-- -°--r--- -
The undersigned hereby certify that the Sewage Disposal System;
Constructed ( ),Repaired.(e),Upgraded ( ),Abandoned ( )
/
he:
has do l 1 d plans/as-built ilt plans relating to
has bee installed��i,u,,a��.. oda� with the provisions ot 310 CMR15.00 (Title 5) p
No dated J /L -C j A proted Design Flow 66 1 (gpd)
application
Instant-1 .l�l fYr I - �
Designer
Lai/ _ Inspector_ • l Date:
The issrunce of this permit shall not be construed as a guarantee that the system will function as designed.
No.;Gee-- %
COMMONWEALTH OF MASSACIIITSI✓TTS
Board of Health l/g 11 frti -2471 • MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Repair pe L rade( ) Abandon( )an individual sewage disposal system
Permission is hereby granted to; Goosvti t( ) a PK
f— J C as described in the application for
at ,�57: Y I s/< -i til
Disposal System Construction Permit No.
,±Lrldateed b -/C- b'
Provided. Construction shall be completed within three years of the date of this pp-mi MI local condidt s must be met.
Form 1255 sec sss am AAA Co eosins.MA Date (P P(c Board of Health -n/f/C
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