App-Permit-ComplianceNo. BQ ` ' ` —! �•- f� 1) 3q
FEE 6374 ` 00
4 " RiowDc- 6 -tom? g f.�e�075S
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f1i o�rr A- MA.
/ Board of Health, ,
APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade e AbandonO - Otomplete System ❑ Individual Components
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Location o eu.)� C„ Lv
Owner's Name Gm'A
J�-
Map/Parcel# a
Address
Lot# -
Telephone#
Installer's Name {-S'8. Co _lN
Designer's Name.
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Address r ()
Address a
Telephone# 14 A q ,
Telephone# �( ' '�
0 L)
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size _�—r— sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures `7 V :�? h C/ �72 (O V
Design Flow (min. required) ` gpd Calculated design flow Design flow provided _SrJG gpd
Plait: Date -< 6 ? I 1 b Number of sheets Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS =Q 1 Qj 1.500 �✓� b �� I-Aj,3 !& + �" .. �`i lSOO
G a k e) fJ ClAIVww�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to notto ce the syste o eration until a Certificate of Com B has been issued by the Board of Health.
Signed Date a'�` �
Inspections
No. 601k DC- 1 6" 10 -71j
/6 11>
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COMMONWEALT14 OF MASSACHUSETTS
FEE, 0000-735"
Board of Health, p (i m n un -y -IAIA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) .[adomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed. ( ), Repaired ( ), Upgraded bandoned ( )
by: a 06 C" "5" R, Oy c C n S nJ G
at Le(-ol S Ret—i RL..VcaI _ -
has been installed in • ccordan with the ovisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. A r% dated _ -i Approved Design Flow (gpd)
Installer r�k4? 1 �-tr,O ai �� YI 0 ji ( s"f
Designer: z_ bj� Z1Vc"(L �$ )EItai InspectQr: 4 _ Date: 6
The issuance of this permit shall not be construed as a gu tee that the system will function as designed.
- No. c r l -IQ) -?75 R ,19 . 0 u* CO. I r i c . FEE
COMMONWEALTH OF MASSAC14USETTS Ck* 007,3253
Board of Health, R"40 U-ni , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) yR�epair( ) Upgrade�,,�''Abandon( ) an individual sewage disposal system
at 3o �ea,21S 20.11 aL Il as described in the
de application for
Disposal System Construction Permit No.a datef
Provided: Construction shall be completed within three years of the date of this permit. A�. local conditions ust be met.
Form'1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date lJ -o^ iO Board of Health
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