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Yki- ,AOUTH HEALToH DEQT.
1146 ROUTE 28
SO. YARMZU ted, MA 02SCrt
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ��r 011`74'1 , MA.
FEE
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
pplication for a Permit to Construct O Repair(') Upgrade(V(AbandonO - &Complete System ❑ Individual Components
Location
7— �Cf �' �" ,
Owner's Name
Map/Parcel#
131 y
Address
Lot#
to Z (J L
Telephone#
Installer's Name
Boy t%!. //1✓ ���T
Designer's Name
Addressuc
Address
Telephone#
Telephone# 3r G- --- �,l3
Type of Building ,� jet e * -- P✓ Lot Size
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Other Fixtures
Design Flow (min. re u
Plan: Date
Title SZf—.,Description of Soil (s) _
Soil Evaluator Form No
sq. ft.
Garbage grinder (-0
Showers ( ), Cafeteria ( )
gpd Calculated design flow Ile Design flow provided / Vq gpd
Number of sheets j Revision Date
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to ace a system in o eration until a Certificate of Co3npliange has been issued by the Board of Health.
A Signed Date
Inspections
No. V
-COMMONWEALTH Of MASSACHUSETTS
Board of Health, XOIOA57L11�4 , MA.
CEIRTIFI�CATE OF COMPLIANCE
FEE
G
Description of Work: ❑ Individual Component(s) Complete System 14 . 1.1 Vy
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (< Abandoned ( )
by: �O� 2�2 &4e
has been installed in acccorda ce with the provisions of 310 CMR 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. eZ b dated /� " '�e�—� Approved Design Flow (gpd)
Installer Installer
Designer: CA nspector: Date:
The issuance of this permit shall not be construed as a guarantee that
theejsystem unction as designed.
No. Y/ �V�/ �� t/r✓�
Board of Health, ya1* Z1,1- MA.
Permissio�n1 is hereby
at / 7 Z 1-
,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
— a 7—oo-
FEE
We'V),4115,
( ) Repair( ) Upgrade (0 -*'Abandon ( ) an individual sewage disposal system
Disposal System Construction Permit No. , dated Uv
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditionsmu be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ���� Gaoard of Health Cmc