187 Application & Permit 2002 c )—
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COMMONWEALTH OE MASSACHUSETTS
Board of Health, hieRI1:1F1lT101.i MA,
ATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
n Construct( ) Repair(S Upgrade( ) Abandon( ) - `Complete System J Individual Components
c.ow Si. -ciao pe..,€
Owner's Nam
Raisin) SILv%i
ddress 1a( L1,u1.) Si.
l81
's Name
SObWad-
Tclephone9(4- � 5(.aG _ 14.36
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Designer's Name j cs M j
n
Address IJk[?V�tseve. /.-Wtrl 5h1
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Lot Size to .1 5-
Telephon
dlding 613-&LE PAINNIL y t4c At
No.of Bedrooms s 4 C
prof Building No-of persons a Showers(�!C '(-)
:uses
m (min.required)
¢44 gpd Calculated design flow 440 Design flow prosided 4S0 gpd
c
f I_jS-64_ Number of sheets a. Recision Date
LAN Of' / erAi tic. (art{) SY51
>n of Soil(s) 4 9 9La ) e. SUL ri v et, cazisn. t 1I ^^
attic Form No.
Name of Soil Evaluator Ichi&Aata`110 Date of Evaluation I/-e '
7ION OF REPAIRS OR ALTERATIONS Mt491-6 -cfNIL)A>(T
S✓RSTANtNR.n 5 EWA 6e n1S
GAh INS-TALL - LSaO • ILC. --T- t it2-li 10 N7
X Pa-) fl A usw 6 ,A,S (_cito ' - ,L Ic) ' .
itsigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
o nqt to plate th;system in operation until a Certificate of m ante has been issued by the Board of Health.
�1Y1..Af Date /l i ci�P.1
FIE.
COMMONWEAL11-I OF MASS1 CIIIISLITS
CERTIFICATE OF COMPLIANCE
of Work: U Individual Component(s) Cl Complete System
igned hereby certify that the Sewage Disposal System; Constructed ( ).Repaired ( ),Upgraded 4-1.Ahandoned ( )
r_
stall d in accordance with the provision of SIO C MR 15.00 (Title ) and the app osed deign I I t az-built I I n. cam
tar,. — dated -
Approved Design Flow [ . (gpCII
Inspector: _ — ' Dale:
re of this permit shall not be construed as a guarantee that the system will function as designed.
'COMMONWEALTH Of 1\SSACHUSLTIS
DISPOSAL SYSTEM CONSTRUCTION PERMIT
m is hereby granted to; Construct( ) Repair Upgrade( ) Abandon( ) an inditidual sewage disposal system
- — as described in the application for
System Construction Permit No. - .dated -
e Construction shall be completed within three years of the date of this permit, All local conditions must be met.
5196 A M.Sulkin CO.Boston MA
Date %
- Board of Health '; 7 4:2 ut