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No. OVIDC 0 0 -PS' FEE i`o�.o
COMMONWEALTH OF MASSACI
Board of Health, MA. �T
t
APPLICATION iC� SPOSA1L SYSTEM STEM C l�NS � CTIOl� PERMIT
Ap lication for a Permit to Construct Repair( ) Upgrade( ) Abandon( - Complete System ❑Individual Components
A
Y
Location L
Fir ri .e
Owner's Name
Map/Parcel#
-2,
Address 14,0
Lot#
Telephone# 5,0 L-5-5 / - r,- - 0 L/� >
Installer's Name
�(� J � Ll. L
Designer's Name -5c,, f -f MC. �,v
Address
A
Telephone# 5G
1.7 r _ Y- ,Q0
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size 4Z-7&sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 7��i� gpd Calculated design flow Design flow provided gpd
Plan: Dater Z `C Number of sheets Revision Date Z
Title fir' 6 fell a'.i/t�/i� %�l/���f��- J^J�►
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS lxs��� f ��
Svclt>
`--x
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree§ to Aot to ce the system in operation until a Certificate of mp 'ance has been issued by the Board of Health.
Signed 1 Date iu
Inspections
COMMONWILALT14 OF MASSACH C46*
Board of Health, kAU-Wil t ,113A
04
CEPITI IC E Of COMPLIANCE
Description of Work: El Individual Component(s) Complete System d
The undersigned hereby certify that the Sewage Disposal System; Constructed V1Repaired ( ), Upgraded ( ), Abandoned
'
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. /4 %Z -- datedApproved Design Flow (gpd)
Installer L'�( �s.v, t.r9 r (It�lu�l� >�011�i,fJ
Designer: �; , ,&T e. 6Qr r-( Inspector: � r' _Date: Gy
The issuance of this permit shall not be construed as a guar ' ,t'ee /that the system will function as designed.
No. 60
c-nko--10d15 1 ` am c- FEE S
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ' SEM"
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;,Constg-ict(0Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. /�,, dated.
Provided: Construction shall be completed within tbx&&-WrW of the date of this permit All local conditions must be ;met.
9 th ) ,1—
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1�
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date o' BoarCi oI rieal .