850 Application & Permit 2016 V/6-/ 7
COMMONWEALTH O[ }'4ASSA NUSETTS
Board of Heath. I r� /U.
M.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
ilication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - U Complete System
dividoal Components
oration qSv (oyS A., go
Owner's Name /%/6/t_
fap/Parcel#
Address j)0 fnsJR/L 66i,'N c lid t /Qnry-�f
Telephone#e,a,.9NL /iN-s7y:5641-t57/ri y3'j/Y—
aft#
nstaller's Name C, Irmek p55„) 7 sj,,,e) J
Designer's Name
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tddress rt9 /poop b'L y�fe OJc(ci /44T%.
Address
'elephone# /i_ (y 36,-5,-95/7
Telephone#
to of Building iewSe do w/7,,
elling-No.of Bedrooms 3
ner-Type of Building 0.472 Ft&CC. e Sv.e>_
her Fixtures
//7
Lot Size sq.ft.
Garbage grinder(WO
No.of persons Showers( ),Cafeteria( )
sign Flow (min.required) gpd Calculated design flow Design flow provided gpd
n: Date Number of sheets Revision Date
le
scription of Soil(s)
it Evaluator Form No. Name of Soil Evaluator Date of Evaluation
:SCRIPTION OF REPAIRS OR ALTERATIONS 47,211/2- 42l Plpce-
/5'60 nL l A_comPB-77mw 7 TA,fit
S'itie 7/r ✓l_
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ke undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther a s t t plac a sys in operation until a Certificate of Compliance has been issued by the Board of Health.
Date 10^ 7r-7L
spections
,J0/( -/7
COMMONWTALTII OF MASSACHUSETTS
Board of Health,
CERTIFICATE Of COMPLIANCE
escription of Work: Individual Component(s) ❑Complete System
he undersigned hereby certify that the Sewage Disposal System; Constructed ( )
r. / C6177 s / /
/2../y/4( r S<fOJ/c T' a,!< B� Q,ji) ({,f5%7/n ,n 7o ' g-+( •
as been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
)plication No. dated . Approved Design Flow (gpd)
'smiler C 2 mP'K V Sort, 5 r� y)n.e/10.4. 1^/(
esigner: Ivspettoc 1.1_ Date: 4 /94-7 /��
he issuance of this permit shall not be construed as a guarantee that the system will function as designed. /
4 ,!
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Upgraded ( ),Abandoned ( )
,„ G//7 -/ 7
COMMONWEALTH OF�MASSACHUSETTS
Board:fHealth, /667/ //It ,• / /V,M,9.
FEE
Oki
DISPOSAL SYSTEM CONSTRUCTION PERMIT
ise-P77 -77M/A--ermission is hereby granted to; Construct( ) Repsair( ) Upgrade( ) Abandon(Kan individual sewage disposal system
as described in the application for
isposal System Construction Permit No. r'(//-/7dated /CC/
2
rovided• Construction shall be completed within th ee years of the date of this permit All local conditions must be met.
m1255 Rev s:ss F.M.slkm CO.raemacwn 1M Date ,C /)./ - Board of Health
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