41 Septic Applications & Permits Na el0
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( 1 Upgrade( ) Abandon( - O Complete System ❑Individual Components
FEE So
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Location k \ D LArl D r n,---f
Owner's Name ALgy e ,) ‘( 1(I-r
Ph.I
Map/Parcel# t� } Ol 9
Address cl ) DUn,i�� 7r
1
lot#
Telephone# `I «3 ' SK to -
Co -)5 `i
Installer's Name ln)cl 1 ¢
Designer's Name }h ) e,�e
Address 5 In e1/4)10 e1/4)10
a .
S)-
Address
Telephone# H i .- 5 a 1
a. 3 2 (
Telephone# :)a3 -
Type of Building A- ' a'C
Dwelling-No.of Bedrooms
Other-Type of Building
Other Fixtures ` 1
Desiggn n Flow (min.required) gpd i design ow
Plan: Date Number ogheets
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
fns
Lt it a-
'2J
H
Lot Size t5 5 75 sq.It.
• Garbage grinder ( )
Showers ( ).Cafeteria( )
Design flow provided gpd
Revision Date
DESCRIPTION OF REPAIRS ORALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
No ','01D FEE
COMMON\CIEALTH OF MASSACHUSETTS
Board of Hmllh, NG T'.v r. �tr� , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired b(fl Upgraded ( ),Abandoned ( )
by: Ifs CA
5.7 . '-•(._
has been installed in accordance with the provisions of 310 CMR I .00 (Title 5) and the approved design plans/as-built plans relating to
application No. i1 0 Hi) 1 dated n -r r o . Approved Design Pow('l !n ce, (gpd)
Installer
Designer 1< I i°-' -( Inspector 1a- I_v Q C 'a(},F l Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
N
COMMONWEALTH OF MASSACHUSETTS
Board of Health, N nr....-('ls. MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE vri
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at i1 DAire.,.1 7,,r.,--e_
Disposal System Construction Permit No. _. I dated -7 j c,t) I - /
Provided: Construction shall be completed within three years of the date permit.,NY(ocal conditions must be met.
Form 1255 Rev 5/96 AM.sWMN Co.ChorsIPYn MA Date )1 X r I. Board of Health
as described in the application for
t$tplo - j
CQNTN1ON\tTEALTTU Of MASSACHUSETTS
Board of Health, 8014-100fLD Ur7 , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application htr a Permit to Construct( Repair( 1 Upgraded ) Abandon( ) - '{I Complete System O Individual Components
FEE ¶t f
Location ITT plan rah N DnvC
map/Parcel# H 3 /
neris Karen KI,eK`aka
hers Name
Address
Telcp"hone#
Type of Building
Other-Type of Building
Other Fixtures
CJ 11 calculated desi flow Design flow provided gpd
Design Flow (min. required) LlL gird gn
Plan: Date Ni‘al Z L 2 flii: Number of sheets f Revision Date
Title HI on I,T VC ve -) 1 ,rid VGI !Drspt,�al 4Ty ;if' m 0 x3ra, P v4 a;npty DiD,IT
Description of Soil(s) 5P C I)n , n. I r i i L, ,1 1 .
Soil Evaluator f mNo
Name f Soil Evaluato 1-7+,,[ P lc Eri:),vl Date of Es ablation /3/3cIVC
Aid ess 41 Dun phi Drive Nori; ll„
lelephone# f3) 5Eb- ; 794
Designer's Name hie ,tole r -
add et. Cole iliJkula E ;,IarK ti f if `v I
T lephone# .4i 4) i-1-7- fin rtl�rc,La�
lot Size /5, 7H-.2 sq.ft
Garbage grinder( )
Showers( 1.Cafeteria ( )
DESCRIPTION OE REPAIRS OR ALTERATIONS I
x `is I rc ( k,w1 tttvl:,h! —
a
r.t;inK • ZuhJnCF� t�xx
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Date
Signed
Inspections
COMMONWEALTH Of MASSACHUSETTS
Board of Health,_�' MA.
CERTIfILVIL Of COMPLIANCE
❑Individual Component(s) ❑Complete System
FEE �.)
Description of Work: Re 'red O_Upgraded O,Abandoned ( )
The undersigned hereby certify that the Sewage Disposal System: Constructed ( ), paired
by.
at
has been installed in accordance with the provisions of 310 CMR 15.00 oved Design Hoce nd the approved design plans/as-built plans relating to
application No. . dated ' ppr
Installer
Designer: Inspector:
The issuance of this permit shall not be construed as a guarantee that the system
Date:
unction as designed.
COMMONWEALTH Of MASSACHUSETTS
Roard ofHrn @A r ' --'
A.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
) Abandon( ) an individual sewage disposal system
as described in the application for
Permission is hereby granted to; Construct( ) Repair b��/C pgrade
at
. .
Disposal System Construction Permit No.- 'i - dated t /r �
Provided: Construction shall be completed mithui three years of the date of chi)permit All local cendidons must be met.
Date _ iT' Board of Health
Form 1255 Hey 5/96 AM Sulxin Co.fioslon.MA
FEE l i/