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h %fir COMMONWEALTH Of MASSACHUSETTS ,.���%-7/
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Board of Health, 11410,
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PJLllCATI®1�® ISP®�3 �7G ]C ��' UMLJCTI®1V PERMIT
Application for a Permit to Construct( ) Repair (wr Upgrade( ) Abandon( ) - 0 Complete System 0 Individual Components
Location
% Oh,
M 20
r
Owner's Name
Map/Parcel#
�'� ZS
Address 5ff /kms
Lot#
Telephone#
,ry�
Installer's Name 1 ' 't�to
Desi ner's Name 1
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Address
1twev� ceul.�
Address
Telephone#
5-Q 9 q 3Z_ q q,5-11Telephone#
D 8 1883
Type of Building rTO i/ 5-k Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. req 're�10
350 gpd Calculated design flow J S�Z Design flow provided � gpd
Plan: Date 4 1 y 4 Number of sheets r /` Revision Date
Title ;;Ok� I)e4 °°SM 4A 7T4444.l'
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONSC-A S r'a. d 6 — +QO Ic t 2�L.(�O �rGl %-►
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to place tem operation until a Certificate of Co fiance has been issued by the Board of Health.
Signed/i.�,�— �" l (i-� Date Z r O
n /
Inspections
No.� FEE /`�'=P a
-71
Board of Health, IUA: j
CERTIFICATE OF COMPLIANCE
Description of Work: ? Individual Component(s) 0 Complete System
The under si ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (01, Upgraded ( ), Abandoned ( )
by: Gam. f, Gr t o K Civ a� a
at M vim, ",e- Ya—
has been installed in cc rd n with the provisions of CMR 15.00 (Title 5) and e a roved design plans/as-built plans relating to
application No. AA
r , dated � `- & a(Approved Design Flow and
Installer / � � &LA, T � 4-41-0 G it C te-� dam( �-� )
Designer: ��'i �� Inspector:] Date:
The issuance of this permit shall not be construed as a guarant a th t the system will function as designed.
No. �/ .'� 7 iA �y �C/�O FEE
COMMONWFAIT14 OF MASSACHUSETTS T// 71
Board of Health,�A44.vla-J�, , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereeb�,. y granted to; Construct(
at 5-3iv `3 O." "-t LA"`
(C,ef Upgrade ( ) Abandon ( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No ? dated S _ )
Provided: Construction shall be completed within tlrree� ter £the date of this pe it. All local conditions must be met.
Form/1255 Rev. 5/96 'A.M. Sulkin Co. Boston, MAAJ %� /'Date U -i C Board of Health Y f�>/