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820 Septic Application Permit & Compliance COMMON\%r{AIJ}H OF MASSACHUSETTS Bourd uJ Hral/h,/W/S IT r1t• y+• IVry MA ICATI'ON FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT o Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Loca. ; , ft kat0 Owner's Name Map/P reel# Address l.ot# ' • '� Telephone# Installer's Name � Designer's Same rmay /�Y'f yyy /• 6t,V%Mi //�� F5 Address Address 9dMd .- Wt �bf Telephone# Telephone# 4is 32--/ 5/-91 Type of Building ,SIN&L5 „ph"v LY Dwelling-No.of Bedrooms I / Other-Type of Building No.of perso42 Other Fixtures / p ��p Design Flow (min. required) in( gpd Calculated design flow 7 95t `Design flow ploy' ed,7 19& gpd Number of sheets Revision Date A tet- Lot Sire*2•v93 ACRG5 Garbage grinder (I< Showers Kr6fe •Ra•( ) Plan: Date Title Description of Soil( 6-3-97 OWL /0 • aQeVS I2fS /0 R6 Soil Evaluator Form No Name of Soil Evaluato Q6 Mt /U • lialuation Date of En DESCRIPTION OF REPAIRS ORALTERATIONS The . dersigned tall the above degtribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and Y'urthe ees m to . the - em in operation until a Certificate of C pliance has been issued by the Board of Health. Signed S — Date bII// ((// 99 .r I nsper lions - No. Description of Work: COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. CERTIFICATE OF COMPLIANCE Individual Component(s) ❑Complete System FEE The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( ).Upgraded ( ),Abandoned ( ) by: at has been installed in accordance with the provisions of 910 CMR 15.00 (Title 5) and the approsed design plans/as-built plans relating to application No. dated . Approved Design Flow (gpd) Installer Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No ( COMMONWEALTH Of MASS4UIUSETTS �� Board of Health, //tom 14472 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissiois rebv grantcdto; Construct(�„Riair( ) Upgrade( ) A don( ) anindividual�ge disposal system at // II C�j Disposal System Construction Permit No. // // dated C/ 777. Provided: Construction shall be completed within three years of the date of thi er it.ylll]b cal conditi s must be met. corm 1255 Rev.5/98 AM.Sulk Co.Boston.MFAM.SWF Co.B ton,MA Jly/w vJ FEE t 2.'cd a �(Q r�J(°( < !� �� a y t /Ee cubed in the application for Date 6 Of Board of Health l/