App-Permit-Compliancer12 " I7' O ooO 9-q
NU. J �d, inC r`9'h c° Cl"
COMMONWEALTH OF MASSACHUSETTS
oG ��
Board of Health, YA R MOUTIA
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgradek<AbandonO - Complete System ❑ Individual Components
bis
Location 1-70L / 4 h {
Owner's Name
Map/Parcel# Raj' - S
Address '� /J j ty —e
Lot#
Telephone#
Installer's Name C l a
Designer's Name
Address r
Address
Telephone#
Telephone#
Type of Building
Dwelling- No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (minrequ
(;IPlan: Date -to
No. of persons
Lot Size sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria
–`gpd— Calculated design flow w/Ll Design flow provided -21' ±!% I gpd
Number of sheets 0 1 Revision Date
Title
Description ofSoil(s) gov-1
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agree install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to p e th system in operation until a Certificate of Co plice has been issued by the Board of Health.
Signed Date
e Inspections
No.
COMMONWEALTH E1-1\JLTH O1C SSAC14 SETTS
Board pouf, Health, Aw o u , MA.
CERTIFICATE OF COMPLIANCE
FEE
a.4
Description of Work; ❑ Individual Component(s) off -Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,. -T, Abandoned ( )
by: -E� /trS Qi fiP J--14tJ C ----V
at 1--7R N J `moi '^t ° (4,ve)
l
has been installed i accordance with the provisions of 10 CMR 15.00 (Title 5) an theapproved design plans/as-built plans relating to
application No. dated Approved Design Flow (gpd)
Installer ! /I 1 (C & r"is 60,6)L L. ./ 1
Designer: d '/'N. C-- Inspector: JEW&I ZMW Date: 7 f 0 n
The issuance of this permit shall not be construed as a guarante�the system will function as designed.
No. 4E t S. eelo- � FEE 00
/64 COMMONWEALTH OF MASSACHUSETTS
Board (f Health, YA 9 -Mo `„ , AM.
DISPOSAL SYSTEM CONSTRUCTION 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 dated AI .
Provided: Construction shall be completed within three years of the date of thisj?,9rrqit. All local conditions must be met.
/ f
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date yJ/ Board of Health _O ` l c ✓ >t .-a e�+Y:�