104 Septic Application & Permit 2005 ( �I IOi�1\\ . -TiIi 1MASSACI�JSETTS
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TION TOR DISPOSAL S fSTEN CONSTRUCTION PERMIT
d 73
Constant ')) Repaii1 Upgrade( ) Abandon( -�IComplete System 1 Individual Components
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Location j4 C//F4 A" St (
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Ownefs Name C//T2SKL
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Map 'Para/ /09 /2(/�,//(/ /'//L
Address f"OC o4 vHa /Aide
Lot# /4/0/gy///9 2g/ -,A/ i/i
Tclephotit# 0�L 9/9,2'Sj/7?0 2
Install
Name �/ «
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Designer's Name O/CL //)/J7 5/F-12-O %i
Address
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Sid //C
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Telephone# a472—"/'7
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hone# y/3 5-3_8sa ]
fape of Building X245/D.F,u7//96 NO/77E Lot Size FY/ST sq. I.
Dwelling-No.of Bedrooms 171/3 t/7y00/v/ C'O o/S/ q Garbage grinder tkiL/
Other-Type or Building /—S//VI G4 �1,/17/(1� No. of persons 5__Showers2).Cafeteria 1tsl
Other Fixtures /'(%tt /3/.2-2 7y� Lf//r/ fU// %/) /%Uiiiii)
Design Flow ((min.required) //C2 k /j/X/.,�pW Calculated design fl flow(Odzi/ Design flow provided 4,' S gpd
Plan Dat 444/ ? CC) ) Number of sheets Revision Date
Title Sr/T/( 51„Tri/1/ /)/=S/G/v 7)62 /4 C//F2/=S e-- /6V /J� /Y
Description of Soil(s) SQe AT///c-/-/Is /J
Name of Soil Evaluator/i(/T Date of EaLianon
Soil Evaluator Form No. - // $/F/I UT/7 fie-
DESCRIPTION OF REPAIRS ORAIIFERAT IONS CO.v///(r //U0/v//) 7)
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3—u -o5T 511- evr r7`I7 94,08
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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 agree y Jo n91 to pia e e system in operation until a Certificate of Compliance o�Seen issued by the Board of Health.
Signed kk ,h// �/ Date
Inspections
No LC.}'ij'
COMMONWEALTH OF MASStACITLSFTIS
Board of Health '1/(7
CERTIFICATE OF COMPLIANCE
FEF �s t/i (�
liA 641/14 72
Description of Work: 7 Individual Component(s) ❑Complete System Abandoned ( )
The undersigned hereby certify that the Sewage Disposal System', Constructed ( I.Repaired ( ),Upgraded ( ),e
at
has been installed in accordance with the provisions of 3
application No dated
Installer
Designer:
The issuance of this permit shall no
s.,.i_'/
be cons
nspecU
ued as a guarantee that the system will function
CMIt 15.00 (Title 5) and the approved design plans/as-built plans relating to
Approved Design Flow (gpd)
will Ultr %! Date..
designed.
COMMONWEALTH Of N�(1ASS;ACHUSEITS
Boma]of Health, 21/l/t.'LW'/`j1l!/ /%/a MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Co struct( ) Repair( Upgrade(v7) Abandon( )an individual sewage disposal system
Permission is hereby granted to; J
,ys . /f/ /('(---(2‘ L j (711196
2 {.-.""7 described in the application for
at / �
i0d51/ dated r.t / 2` AJJC
Disposal System Constnteti n Permit A o
Provided Construction shall be completed within Mee}ears of the date of tlys-permit. All local conditions must be met.
Form 1255 ReJ 5,06 AM SNkm La.BOnaA.MA "Pile
(.t ' %t Board of Health %
FEE 6Dfc)b
-0132/73