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No. t364DC
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COMMONWEALTH OF MASSAC14USETTS
Board of Health, Y"1'i Q Lrj J� , MA.
FEE l) 5,00
I(03
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade() Abandon( ) - Complete System U Individual Components
Location
jf � dC/rif P-
Owner's Name
/4 /1J d/l/ YiMfi,�5
Map/Parcel#
3 6 f
Address
,4,1 e
Lot#
Telephone#
Installer's NameQd✓
W.4 /k e,/
Designer's Name
yrs ��1f, � t.✓d�r�.d
Address
aeA �� ,� jtj
Address
Telephone#
9 I– -7 d
Telephone#
GIr 3 �d
Type of Building P
Dwelling - No. of Bedrooms L/
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s)
Soil Evaluator Form No.
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
y gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the�tem in operation until a Certificate�of�mp1j ce has been issued by the Board of Health.
Signed ` '` Date t.
a Inspections
s
No. 1�0-2—
COMMONWEALT14 OF MASSACtUSETTS
Board of Health, nt 1:::i:::4
CERTIFICATE Of COMPLIANCE r,ri.:�,? t
Description of Work: ❑ Individual Component(s) -Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( CUpgrade
d ),Abandoned ( )
by:.
at / L/'� tc1 //ils�'r�Griy 06,a/ -
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
s .
application No. �l/ ;;;"/' , dated / /� 2 `/A Approved Design Flow 4/441 (gpd)
Installer le
Designer: r !' Inspector: i s e cam ' Date: -7- / S 'r' d
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No 4) �.. C I b " 3 1 %'� 1 `1 �}-0e FEECOMM 6-NWEALTH Of MASSAC14USETTS 44, 100-3
Board of Health, Vaano yr A , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade) Abandon( ) an individual sewage disposal system
at 4` 7 44 l�'?� �"7 , iy Gf' __._ .
f ,�^ as described in the application for
Disposal System Construction Permit No. / ( i ��r, dated
Provided: Construction shall be completed within three -yearns -•the date of this permit. All local conditions must be met.
a 0�, C-1
Form 1255 Rev. 5/96 A.M. Sulkkii co. chadestown, MA Date / f '- � Board of Healt _��� (%,✓�;'�