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COMMONWEALT14 Of MASSACHUSETTS
Board of Health, Nm -
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(---) Upgrade Abandon( ) - Ll Complete System :QUI vidual Components
Location '36 L
Owner's Name GL
Map/Parcel# 087
Address 3
Lot#
Telephone#
Installer's Name
Designer's Name ae,
Addressqq
Address
Telephone# �� _ �(�
Telephone# 36o 33/
Type of Building A`Qg io'"-11 Lot Size sq. ft.
Dwelling - No. of Bedrooms AA Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3_30 gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil(s) _
Soil Evaluator Form No,
Name of Soil Evaluator
Design flow provided ?5_0 gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS -141S'M l l 11l -CW L 4949Cif?«1 r `V- I J r
The undersigned agrees to ins above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to no o lace a tem in operation until a Certificate �o+f Compliance has been issued by the Board of Health.
Signed h
Date ' 7-16
Inspections
FEE . 0o
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y l )UTY , MA.
CERTIFICATE Of COMPLIANCE P�tr�
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigne hereby certif ;that the Sewage Disposal System; Constructed ( ), Repaired (LT -,,Upgraded ( ), Abandoned ( )
by: tm 5
Lei -
at \j --fid (114,� vb
has been installed in accor nce with the provisions, of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. J ,dated "' 7 - 0. Approved Design Flow 3_s (gpd)
Installer M�''t`t"t1�(
Designer.6- �'_ ° � �i�% �- Inspector: rC l% � Date: Al
f
The issuance of this permit shall not be construed as a guara at the system will function as designed.
6�t; p C c.
No. 1 �. b 1 l I Z_ I� �? i but FEE
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COMMONWEALTH Of MASSACHUSETTS_#4° 0
Board of Health, Yh:amoyni ' , MA.
DISPOSAL SYSTEM CNSTRUCTI®N PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. �I�-
k73, / dated G�
Provided: Construction shall be completed within three years of the date of thisermit. 1 local conditions m st be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ��Board of Health p -�//�