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COMMONWEALTH ®F MASSACHUSETTS LSTR4o, 06&5 0S
Board of Health,1 , MA. 2-0-74
APPLICATION FOR. DISPOSAL SY TEM CONSTRUCTION PERMIT �
Application fora Permit to Construct( ) Repair( ) Upgrade Abandon O - ❑ Complete System ,O'individual Components
Location E
l- e -en b -71-1w Ci) `{
Owner's Name
Map/Parcel#
tS
Address
Lot#s
! J-'
Telephone#
Installer's Name
1L� (LS , �'is1�-g f� & it
Designer's Name LI /'L O -h 0n4` -1J
Address �`�
i h-- d y s.
Address %0 0 C,�O�
Telephone#
S (z!w
Telephone# S e F- "s; & L't
Type of Building Lot Size d ;-- 1v / sq. ft.
Dwelling -No. of Bedrooms u Garbage grinder (41?
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (n
Plan: Date
required)
Q/gpd Calculated design flow L % Design flow provided. gpd
Tw -/} r)f Number of sbeets % Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Name of Soil Evaluator � . Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS Se -f S -Pah ( &S)
The undersigned agre s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to pla the s to until a Certificate of
Signed omplia ce bribee sued by the Board of Health.
E� -• '� �`� Date'"��` <9 `✓'r
Inspections
it
No. X—�Q—I1V8� � / ( /",7 E c�iy
COMMONWEALTH OF IIIA SACHUSETT # - /Ck.
Board of Health, MA.
CERTIFICATE Of COMPLIANCE s
Description of Work: ❑ Individual Component(s) O Complete System` a {
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The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),Upgraded 'Abandoned O
r ra r. ;5 k -
by:, Fri ; d,1�� �, , •�, ��J �'=
has been installed in accord nce with tlafe'puovisions o 310 CMR 15.00 (Title 5) and
application No. / , dated " ? . Approved Design Flow
Installer %_I_i_��� �Ez -? ra 4 (( -L ..,�
Designer: "1:A n It ltt ,1 G t ; f. t'J Inspector:
The issuance of this permit shall not be construed as a guars
No. _V�>04DCAO -f ®
design plans/as-built plans relating to
dee that the system will function as designed.
COMMONLTII OF MASSAC1 USETTS
Board t f Health,c � , MA.
DISOdSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system
at a c, L -a rj i . J4 i . <a r` n e.-, , as described in the application for
Disposal System Construction Permit No , dated - 7_f
Provided: Construction shall be completed within t xcC Pars,.off` the date of this perm't. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestown, MA Date l 1, Boa`jQ of Health