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COMMONWEALTH Of MASSACHUSETTS 6"HNI
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Board of Health, _ 01�, MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(�Repair( ) Upgrade( ) Abandon( - Vc,mplete System ❑ Individual Components
Location #fes TOC fle_h,, e, c;e,
Owner's Name /4.W�,.e�✓ �� b �s
Map/Parcel# (i �-g . �J 9
Address Roo /� �/� ��J; ,�y► �`¢���✓ 'e#.
Lot#
Telephone# 1-7
Installer's Name--. A J, c �� o �Sn NG R,A.y
Designer's Name
Address �d, r3 •`?r 7°fS~ S'As} nekx_ 414. O26?0 /
Address
Telephone# e, J 3 60 - Sr4f e
Telephone# _q,!,
Type of Building Re S iJC-A4-L-- . Lot Size a S CAPD sq. ft.
Dwelling- No, of Bedrooms Garbage grinder( )
Other -Type of`Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) j�/� gpd Calculated design flow Design flow provided�gpd
Pull: Date Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS .1� £fg "' Alw�
iC'rien An✓ .,L• --I :2Z A_%c
Date of Evaluation
The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ._ Date ///%q 16
Inspections r f f � A
d14-
Board of Health, YagAouni MA.
CERTIFICATE OF COMPLIANCE
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Description of Work: ❑ Individual Component(s) ❑ Complete System /
The undersigned hereby certify that the Sewage Disposal System; Constructed), Repaired ( ), Upgraded ( ), Abandoned O
by: S ,
at G C (l u e 4 A) e r l f-aC
has been installed in alcc rdance with the provisions 0 CMR 15.00 (Title 5) an proved design plans/as-built plans relating to
application No/=.d�, dated Approved Design Flow — (gpd)
Installer too k A LJ r. ELL -0
Designer: f 1P,C- .}� t�1C, i J)C- Inspector- V Date: ^ ✓ /
The issuance of this permit shall not be construed as a guar a that the system will function as designed.
---' No. 6owx —! (o —i 'i -13 S-0 NG IQ14y/ f f FEE It 0. 00
16, JQ 3 COMMONWEALTH OF MASSACHUSETTS
Board of Health, �Yf' QMA.
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(] `Repair( ) Upgrade¢ Abandon( ) an individual sewage disposal system
at ����;�.0 fel, o 0 Nj rte' C �'/ec _.�� s'~1'' y as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within ibx x_y=rAf the da e of this peryit, All local conditions must be met.
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Form 1255: Rev. 5/96 A.M. Sulkin Co. Chadesfown, MA a��t�' 41_//'Board of Health
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