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
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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/