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16- COMMONWEALTH Of MASSAC14USETTS
Board of Health, V&M.O UTVk MA.
APPLICATION CATION OR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Applic tion fo a P rmit to Cons ruct pair( Upgrad ( ) Abandon( - ® Complete System LJIndividual Components
Location -
Owner's Name -T-t4z,UNG-1=
Map/Parcel# 2
Address 30
Lot#
Telephone#�
Installer's Name7�R;r---y^T j
Designer's Name �- M
I
Address 2 1 1`Q�,iJ tCJtq
Address 15- 3 t -JA ) Vf
Telephone# 4 -ao
Telephone# 5p$- - (p
Type of Building Lot Size�Jc sq. ft.
Dwelling - No. of Bedrooms hy Garbage grinder( )
Other- Type of Building No, of persons :I-_ Showers ( ), Cafeteria ( )
Other Fixtures 0<7
Design Flow (mina required) �k-_)0 gpd Calculated design flow '7'2 C> Design flow rovided gpd
Plait: Date " I,=> " I to Number of sheets I Revision Date
Title `�1 -12152-D--l-Adt-
Description of Soil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Date of Evaluation �, - ( to
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further not t p ace ystem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date Oilir -I Ly
Inspections
Ali?
3
2
No. 01 C 1 -4D 2q FEE , U
COMMONWEALTH OE MASSACHUSETTS
Board of Health, MA,
CERTIFICATE Of COMPLIANCE
Description:4af'Work: El individual Component(s) '6 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded ( ), Abandoned ( )
by: C.A G-
at
has been installed in accoulanr.e with therovisions of 1 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated ` / ---4. Approved Design Floye,4 )
Installer �°
Designer:�; ► PV1 . ZLIN Inspector: � Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
-- 120 q DC_ f" h'1 a off) rs OG- FEE
/ r 2aj COMMONWEALTH -®E MASSACHUSETTS
Board c f Health, 0 k;- , M-4-
DISPOSAL
A.DISPOSA L SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at -Ar=-� E.UA t, as described in the application for
Disposal System Construction Permit No./ dated 7 """!j /ft.
Provided: Construction shall be completed within > W&ite of this permit. ANjocal condi ti ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA / Dr CL Board of Health