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No:
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FEE FC)
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c Board of Heal46 ROUTE 28
N, MA 02W
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (j6 Abandon( ) - ❑ Complete System J10ndividual Components
Location
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Owner's Name 3,.D
Map/Parcel#
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Address
Lot#
Telephone#
Installer's Name U `�Z
Designer's Name
Address
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Address
v oeYVV S XcA Cb�.,r,
Telephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow �� °' Design flow provided �'��'- gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS;
The undersigned ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of pl the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
`ttnspections
Board of Health, MA.
CERTIFICATE OF COMPLIANCE �-64A s le- :r/ 6II&
Description of Work: Individual Component(s) ❑ Complete System
The undersigned V hereby- ertify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �, Abandoned ( )
by: �'r'��..
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the ap r ved design plans/as-built plans relating to
application No. +.' ' / 6' , dated .Approved Design Flow id�:� gpd)
Installer -tf, ,.- 131i Arc--^ f
Designer: /1't'lF'vliF (� �t% Inspector:
..� Date:
The issuance of this permit shall not be construed as a guarantee thatffhe system will function as designed.
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No. ("I� �' '1 FEE ;�
COMMONWEALTH OF MASSAC14US ETTS `lei , -6
Board of Health, VV�l. LL /77- , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is herebygrantedto; Construct( ) Repair( ) Upgradepd Abandon( ) an individual sewage disposal system
at (/1/���7� c 2 as described in the application for
Disposal System Construction Permit No. 7s, dated
Provided: Construction shall be completed within "' s of the date of this ex it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date Board of Health , J /�'