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COMMONWEALTH Of MASSAC14USETTS
` Board of Health, Y Q JM , MA. KX,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION
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Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - Q Complete System ❑ Individual Components
Location
Owner's Name e n e
Map/Parcel# b
Address4L/ �f_ 11
Lot#
Telephone# L50 k `3Q kj— 3 7
Installer's Name
Designer's Name Tkt e C
Address _� -
Address IY L9 B0 grly-o Ax,
Wer
Telephone#60
Telephone# T)LI —
Type of Building � _� Lot Size b t / C� sq. ft.
Dwelling - No. of Bedrooms - Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 330 gpd Calculated design flow Design flow provided gpd
Plan: Date '11-13-16 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
The undersi agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr s to o place th t eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date I t —'�'
A Inspections
No. l t "{ ? `,.` FEE..
-
COMMONWEALTH OF MASSACHUSETTS * 4qs ?
Board of Health, Y A NrA.
CERTIFICATE OF COMPLIANCE
Description of Work: ,� I idividual Component(s) ❑ Complete System
The un. dersi ned herey certify that the Sewage Disposal System; Constructed
� y g p y O,Repaired( ),.Upgrade ),Abandoned ( )
by: I
1a -; kn r X C-1 Lt j J
at
has been installedinaccordan with the provisions of RO &R 15.00 (Title 5) and th proved design plans/as-built plans relating to
application No. %�� dated !l` i'/ . Approved Design Flow (gp_$l') ,,,y
Installer :n i° i=tA
Designer: ,( s Inspector: Date: l
The issuance of this permit 1.11 not be construed as a guarante at the system will function as designed.
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No. P: 0 � k) ' 1 �:. ^" { jZ�, 5 t fes? f__ -A CA AT, ()IQ FEE Gtr.)
COMMONWFALT14 OF MASSACHUSETTS C.3
Board of Health, Y62MO U 74 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrad Abandon( ) an individual sewage disposal system
at "�l z . t l tol • C r -o _ t _K _00,,Q. �n df w ` f as described in the application for
Disposal System Construction Permit No.�, dated
Provided: Construction shall be completed within-+rFe'Vn of the date of this permit All cal conditiopt s must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date !�' �` oard of Health