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No. 6 �� t0 0 lV J FEE v v `oo
BBDOD C-{ 6-{ 08,4 (o C®_X4 ® ITIT . ®F A4 A CC A CTIUSFTTS
16 Board of Health, MA.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER I
T
Application for a Permit to Construct( ) Repair( ) UpgradXeAbandon( ) - Complete System ❑ Individual Components
Location
1 s
Owner's Name'fa- Q
Map/Parcel#
3 179'16-9
Q
Address 40 kwce-- St
Lot#
Telephone#
Installer's Name
P k M Con-f-rQc�D(g U
Designer's Name O
Addressn
S
Addressq3q rj-�i„ mo
Telephone#
-9)?
Telephone# c�
N
Type of Building I
Dwelling - No. of Bedrooms
Other - Type of Building
Lot Size sq. ft.
Garbage grinder( )
No. of persons —Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. reuired) gpd Calculated design flow '336 Design flow provided gpd
Plan: Date_ 'i f 'i/0W /6 Number of sheets -I Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
OF REPAIRS OR ALTERATIONS e X �J (.Oc i! 1 O n
O n n i i n ., 4--A n ii v 14 Chl, i`n o f A
The undersigned agrees to ujaAtall the above dmmbed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pl }n ' ration until a Certificate of Compliance has been issued by the Board of Health.
SignedDate 61
gl /
Inspections
No.F�COMMONWEALTH
t FEE c t
Of ( lilt 1J ETT
ti
Board of Health, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ale-mplete System
The undersigned hereby,cegify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded
Abandoned( )
by: (il C't,
at mtranor V05d.
has been installed in,accor>d>an with the provisions o)&310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
-�-✓. Approved Design Flow (gPd)
No. -^� 0. dated
application .'� f!7
Installer
Designer: i it Owe Inspector: ` `'"5 Date:
^ /
//
The issuance of this permit shall not b construed as a guarardee that the system will function as designed.
No.
FEE J 7, .. 00
COMMONWEALTH V'I' EALTH ®F MASSA'l 14USET T S
`�
Board of Health, O 6" , MA.
SYSTEMDISPOSAL
_. � - r . CONSTRUCTION
TA N PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgradb,,�,,) Abandon( ) an individual sewage disposal system
at—0 1 01► rfa r 1��'UL>iL- ao 0 ( %'`! as described in the application for
Disposal System Construction Permit No. f�r9 �.� , dated
Provided: Construction shall be completed within %ret vears.ef the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestowe, MA Date .+a3 ` / 1 ^ ! �o Board of Health �/ !�