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No. (o -40K3 1-4
'. 11 ,—A
��4' � FEE 0-,, 00
C®N MON LTII OF MASSACHUSETTS5b-77,3
Board of Health, V4 W.00TV , MA.
APPLICATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location -
Owner's Name
Map/Parcel# to l 156
Address
Lot# . (j (
Telephone#
Installer's Name`
Designer's Name ®`
Address
Address -� l
Telephone# I
Telephone# 36a q Q a,
it 55Q�
Type of Building Lot Lot Size sq. ft.
Dwelling - No. of Bedrooms �� 3 Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 110 gpd Calculated design flow -3,30 Design flow provided 3y o��'o1J� gpd
Plan: Date 1 71 V Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator M , a
of Evaluation 5
DESCRIPTION OF REPAIRS OR ALTERATIONS -AA-t) Q In -l/) (oli IA4 0fL �►.iN�
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 system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signedy Date 6 l 1 Y 116
Inspections
COM MU I.TII U� YlASSALHUSUIS aV- Ck 50 273
Board of Health, OpaAOu-m , mA. QV
[S " � tv
CERTIFICATE Of COMPLIANCE
Description of Work: ndividual Component(s) 91"C' omplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ((/ Repaired ( ), Upgraded (/Abandoned ( )
by: ` 1
at U9 m �
has been installed in accorAdnce with the provisi ns of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. `/ dated A Approved Design Flow
Installer +A,
Designer:
The issua
Inspector:
Date:
of this permit shall not be construed as a guaraptee thaf the system will function as designed.
U C 1 p 00 C01- 0 c.oC , - 0 coccocoOG ,,
No. ` FEE
COMMONWEALTH Of MASSACHUSETTS 4#50 /-7.3
Board of Health,ASA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(t4 Repair( ) Upgrade() Abandon( ) an individual sewage disposal system
at
Disposal System Construction Permit No j41
dated
as described in the application for
Provided: Construction shall be completed within ,tlixeyceaxs.of the date of this permit. A,111oca1 conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date/-$oard of Health