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No.
+ISO 1JC'(%-2Z0� COMMONWEALTH OF MASSAC14USETTS 007�d(oI
Board of Health, VAhOGIN , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( ) - Q<Implete System ❑ Individual Components
Location L�
Q �"
Owner's Name J v (
Map/Parcel#
1
Address
Lot#
Telephone#
Installer's Name R� j l'
w�V`t� Co e -j PC_
Designer's Name
Address
VO b0 iS3
n
Uv (
Address -
o .QO)( 1,)(0:3 Ci_0
Telephone# ` C
5
Telephone#Cj -! ..
Type of Building Lot Size 1$, L sq. ft.
Dwelling - No. of Bedrooms S Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures f 5 _3
Design Flow (mina required) 5�� gpd Calculated design flow Design flow provided gpd
Plait: Date (Ci 11 Number of sheets -T Revision Date
Title
Description of Soil (s) 1'
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS /I,N, S� Q
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 ice theessjte operation until a Certificate of Compliance has been issued by the Board of Health.
Signed /s'si� ���/n /Date
Inspections 01%
/ / < vt sip p c', !► l Irt �lC
u� t %J�/Y�' d� �� `
No. FEE
COMMONWEALTH OF MASSAC
Board of Health, , MA.
CERTIFICATE Of COMPLIANCE --.r� �-�� �-- 0
Description of Work: ❑ Individual Component(s) Q GVm'm Tete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded , andoned ( )
by: ,
C-
at
-� r - 4%
- t 1-rs�—�tL''�__-/'1r_---
has been installed in acedkdance with the provisions of 310 CMR 15.00 (Title 5) and
application No. dated Approved Design Flow -L
Installer
design plans/as-built plans relating to
Designer: G nspector: �� E_ _ Date: ;7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. r e T =1 F � � , iy, ® Q 4 FEE
�.- COMMONWEALTH OF MASSACHUSETTS
fit, Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (�„}.�liandon ( } an individual sewage disposal system
at _%Q&2>j a (, as described in the application for
Disposal System Construction Permit No. J dated
Provided: Construction shall be completed within ��t date of this permit, 1pcal conditions must be met.
Form 1255 Rev. 5196 A.M. Sulkin Co. Chadestown, MA Date .2--1^Board of Health
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