878 Application & Permit 1998 Appl
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health /C1=72%-7//sU%2,0Td4.
LICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
1 ion 875 Cu-pSJ4io ,,,,,kt/
Owner's Name 41,01,1A/ k/.4
q'ea
Map/Parcel#pNO2%i////7f7 .I) /f4
Address eye et.ef/44j/' ?,Ap/coma,
L,i# rJ yC/ eUl i///rinfiA1i igo
Telephone# /U027`/i,i , iJ`//N 0 tz-/
Installer's Namc'jy t0' (.V , Co rn.)
Designer's Name Ai/GG/042 5, 2C'J/
Address sue.e S% sr W. th-T f c/J rvr 9
Address «l!/ed,/&/7l///
Telephone# q i 3 0_Y p_ ? 0 B
Telephone# /ffjea Ice ,s--7/9.5-5
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Type of Building /25457C0,7 YCfi AEI...Lk'
Dwelling-Nn.of Bedrooms 3 B�0200mf La // ‘,/ Lot Size k'T/Slg.ft.
Garbage grinder(y!PY v
Other-Type of Building /
Oiher Fixtures /OGL /5"---n'7- e /n' ,O/SP ft'/ 60/1 2.0 .1-
Design Flow (min_required)/10 vpJ� r/S d Calculated design flow V95-- Design flow provided �%7 (mod
Plan: Date �J&f /9 ///I"9 Number of.sheets
Title i r P Xe c
Description of Soils) f ° O /4/ ?../9 as-go
/1 Name of Soil Evaluator ---746(.1 ate of Evaluation
(O Show ),Cafes °/
No.of persona a
Revision Date .eti6
/icy in k/7 Z, £4
Soil Evaluator Form No.
/906 /z /99f
DESCRIPTION OF REPAI KS OR ALTEL)TIONS r0/ /id. _cry Li/arch
00 ."-ex�l�P P /2e o -7 f
The undersigned
further agr
Signed
C
o inst ab e described Individual Sewage Dispossssss������Syste//////°°°°°°i accordance with the provisions of TITLE 5 and
dace the m in o eration until a Certificate of�f Ban has been issued by the Board of Health.
Date (� iVV
Inspec lions
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Ne,_ 5g- 9V
FEE
CQMMONttll OF MASSACHUSETTS
Board of Health, , 17/t , MA.
// CLPTIEICATE OE COL IPLIANCF
Description of Work: La'Svdividual Component(s) Wempiete System
The undersigned hereby cer}i7'that the Sewage Disposal System; Constructed ( ).Repaired ( ),Upgraded (),Abandoned ( )
by: ; ./c
at 9-2 G (:4 , ire°yt, ) • L7 ---7, •
has been installed i cord: -e with the pr W i
u s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No._ lj 1/ elk dated /' //S/ 5 . Approved Design Now 4"%% (gpd)
Installer )7 ' (/ ( 1-, /Z,/
i
Designer: /is al i/Frr 1 -/!L Inspector: _ t r
/ p
are: / < - /�_J �
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.�`� `/— ' A ' j / / / �\
Li- 7 f/ , I FFE �V
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /1,47af!'IZ44. J?4 Th MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby gra{/ited to onstrucr( )�epair(�Ltpprade( ) Abandon( ) an individual sewage disposal system
at O 7 p ✓(/-e ,7.*/ / /J —V'(`J as described in the application for
Disposal System Construction Permit NO 5'1—n", dated /47/ti/f.
Provided: Construction shall be completed within three years of the date of thi er 't. tcal ndid t.ist be met
Farm 1255 Rev mss AM.Sulkir Co Barton MA Date /l /05/Board of Health J G)° s