15 Application & Permit 2004 2-60V-37
COMMONWEALTH Of f'
ASSACIIUSLTTS
Board of Health I0,41}AMP{pt• • MA.
FEE
;it '
3293
APPLICATION MP DISPOSAL SYSTEM CONSTRUCTION PERMIT
ion fora Permit to Construct( ) Repair( ) Upgrade% Abandon( ) - O Complete System KIndividual Components
on I S Ali re_WAy liPade l t,Idltah1-f3t e)
Owner's Name Cli^KISap 4}2+2_ 5 %a.04q
Parcel#
Address fl Fkl ass 4t/ DO-WE,t nkl`Rg i-P n1 pf n..i
Iblephone# 413-5Ek-4965
Designers Name yam, G5110E1$tWG
erS Name sS
ss 17 rw1n
t�� yl ah J/ y //,�� NN
' t .cL %{Ulfrul1a- m4
-ij3 /
Add'esscoLt, esai41+W)AY4 CLARK 5rItAr ' P.O,eatI
Telephone# 413-52"I-31.00 SoJRlhtt'pfot�
,one# (-4«3
t'x�f�
nomon
snnaing tioosE.
-No.of Bedrooms 3 (3ebPAOr1
Lot Size
101000 sq ft
Garbage grinder( )
Cape of Building No.of persons Showers ( ),Cafeteria ( )
zmres
low(min.required) 340 gpd Calculated design flow 241 Design now prodded 249 gpd
rte_,5epf sue/ 2004 Number of sheets I Revision Date
Aid Of PRoTbte-D seviActe bwm4l.SyS1i'r■ippAente IU 000-11ygrt Pus..:
ion ofSoil(s) SE-6 'Para R)L Solt- l.t1QS
uaror Form No. Name of Soil Evaluator HMS-?• Rota Date of Evaluation II/2-4'/03
PfION OF REPAIRS ORALTERATIONS Tns acalon of 1000 541101+ Pimp Chamber' rJ boa I
>0 leach eld - i- +
< ...
+n exlsithlo raised pert k above -Fork.
• Set Form 9A - Svakxn Redu
ersigned es to install the above described Individual Sewage Disposal System in accordance with the p
rgr t t to lace the sys operation until a Certificate of C prance has been issued by the B.
/ Date 2e
MS
e
don of Work:
iersigne..d hereby ce
COMMON WEALEH of MASSACHUSETTS
Board of Health, I / 7,1
CERTIFICATE OF C$D'`PLIANC{
ndividual Component(s) ..❑Complete System
that the Sewage Disposal System; Constructed
),Repaired ( ),U.gmded
w 4
FEE
[
(224#3z 3
).Abandoned ( )
IVA-
installed in accorda with t
provjsions of 810 CMR 15.00 (Tide 5) and the U approved design plans/as-built plans relating to
Approved Design Flow)y I (gpd)
ion No U dated
'f ,Zoa
Inspector:
Lance of this permit shall not be construed as a guarantee that
/
Dam: C3
�-s/7
em will function as designed.
COMMONWEAIT1 OF MASSACHUSETTS
Board of Health, A '��_.�/ rr/:/ , Aid.
DISPOSAL SYSTEM CONS UCIION PERMIT
FEE
2413
Lion is hereby granted to; Construct( ): Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
/ J lLl✓:r 421 U —' �- -t o31t t^q )l - as described in the application for
1 System Construction Permit No. 2x1/-3 / , dated
d: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
3s.
5196 n.m.somo co.aos:oo,MA Date aG4,U/O`'Board of Health