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App-Permit-Compliance-1I 17i�� L<� _ �� S��P FEE /7 Idy COMMONWEALTH Of MASSACHUSETTS C14 036-3 Board of Health, i&E&Q 07-74 , MA. APPLICATION FOR DISPOSAL. SYSTEM CONSTRUCTION PERMIT plication for Permit to Construct( ) Repair( ) Upgrade Abandon( )-a.0'Complete System ❑ Individual Components Location D(. e W U F17 Owner's Name ZEA &INE NESS (Q A j Map/Parcel# 8® -3�o Address jqf m(L-I©tj pA gPAtwrtRe6mA Lot# t a Telephone# Installer's Name �� C�A�G els Designer's Name ��j�l�y�- �i 0 S L Address GD >ptEF'Address �� W�C,6ZtiSS-lt 14,-b d t Telephone# S - V7 -7 - g� Telephone# . 4 ,.. J { Type of Building Dwelling - No. of Bedrooms Other - Type of Building _ Other Fixtures Design Flow (min. required) Piaui Date Title , rZ)L EWOO7)_ Description of Soils) _ Soil Evaluator Form No. 1 Lot Size t 15 ,4 O+d t sq. ft. Garbage grinder( ) No. of persons Showers( ), Cafeteria ( ) gpd Calculated design flow Number of sheets i2i11>� iI Name of Soil Evaluator Design flow provided 54-2 ► -7 gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS -TiU3-rX E- lUdDC) 4S-C>0� �� ^�7 1 -1 -IO �Ei�'LlC-`TSU ,2m wt --w H - 2 U o r-4 oX Tn (a) Le (e 46A4o .t - S Lv chi 3,S f'r- of= 4he 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. Signed Date`" Inspections %SEE 6D FOMM 0 NWEALT OF MASSAC Board of Health, ��n U_, MA. ` CERTIFICAT ` Of COMPLIANCE Description of Work: ❑ Individual Component(s) omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgrade, Abandoned ( ) by: CAPE (p6- at t�"�• i1C—fib-` i has been installed in accordance with the provisions /off 310 CMR 15.00 (Title 5) and the a roved design plans/as-built plans relating to application No. '- dated f / . >Ap jprr�ogved Design Flow-y(gpd) Installer (�/ mujibE g;AREkPI i. g ��:ae��^�'� 0-0— tj fDesigner: Etjr=U)E�W (A)r= Inspector: Date: a The issuance of this permit shall not be construed as a guaranrllhat the system will function as designed. / �4��;L No. _ � fd.*A pew 1,V E` FEE COMMONWEALTH OF MASSAC14USET TIS Board c f Health, YAg M7 A i n!7:- MA. -APOSISL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) UpgradcAbandon( ) an individual sewage disposal system AN at -j S -7-bL j5'(AJ ©d -b b&.) !)E7 as described in the application for Disposal System Construction Permit No. dated -C— Provided: Construction shall be completed withins o tf he date of this per ' . All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date _ -Board of Health