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� ' ,J7 / /� EE �i DCOMMONWEALTH OF MASSACHUSETTS ;F4,*
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Board of Health, �LP� 0 l� , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrade( AbandonO - ❑ Complete System Z Individual Components
Location `a% --L AA/fled
&0 , s
Owner's Name
Map/Parcel# `]
Address
Lot#
Telephone#
Installer's Name r'� 1S
Designer's Name 7.
Address A 3 En t!C ,Si
-Quyep
ddress q31 1
Telephone# S '3
Telephone# S s
Type of Building Lot Size % (% sq. ft.
Dwelling - No, of Bedrooms �� Garbage grinder ( .f V0
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min/�
. required) _ gpd Calculated design flow �— Design flow provided gpd
Plait: Date 02 / " Number of sheets Revision Date
Title /r / °C ew / �//ir YiJ� a� ��t &-, �, '401 ..�A,011 _ _ `L� lJf�iO l
Description of Soil (s) 5 O rf
Soil Evaluator Form No.
Name of Soil Evaluator % l ` Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS SQP Qs?J`yr 1340 Sq t::),
The undersigned agrees pgimstall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no o lace t in o n Certificate of C m ince has been issued b the Board of Health.
Signed !� � Date P ✓ y
Inspections
e
No. FEES C+
r �~ COMMONWEA.TII OF MASSACHUSETTS dt-* 35-8 2,
Board of Health, 4QJM0 ra , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: 21-ndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded�andoned ( )
by: l C--7 < //
at , f_ S, B1 fJu• ``
has been installed -M, of/RKje-' v h t e i o si ns of 10 CMR 15.00 (TX, 5) and�thhearoved design plans/as-built plans relating to
application No. dated % Approved Design Flowpd)
Installer t?LtAj&r /-Wr- i CC,)
Designer: �e•n.,t� Cet�,p ��1Tre Inspector: V Z) L/— --, Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. to - C)os-()FEE �, 00
Board (f Health., MA.
r DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to,; Construct( ) Repair( ) Upgrade Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No.
Provided: Construction shall be
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA
deset`ibed in the application for
,p eted within res -of them� t�e date of this permit. All local conditions must be met.
Date J /� Boar of He411-r