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Board of Health,MA.
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair" Upgrade( ) Abandon( ) - ❑ Complete System Individual Components
Location 1111Off%'" D
Type
Owner's Name % ft,Vt -7- D ili4%r7QN� I-
Map/Parcel# 020 Z 166
Address c;�/ 40.9KA1 &J)431
Lot# %�
Af
Telephone#!
Installer's Name /�<< (�f G FN1�/'*/c�t1�4%/I,�ijC
Designer's Name
g 01F-1EIZ A 500.5
Address����� ��� ��Q,gy�
Address , 0, -6bx 9 0 1 Z-, 5A4AJd101 C. H
Telephone#` ® 9 •- 62
- _ 0 -
Telephone# -5-09-360- 9,::3/1
Type of Building
Dwelling No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (mina required) .� Gam% gpd Calculated design flow 253;77 Design flow provided gpd
Plan: Date Number of sheets Revision Date ��:� `�✓r
Title
LLI11%LT Lot Size !&Y7 sq. ft.
7 Garbage grinder ( )
No. of persons Showers( ), Cafeteria ( )
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees o t to la the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed `v/ Date 12- /'-46
Inspections
a
r
No. e2oqix Ko -18q-7 rl-tlj, 44- co
COMMONWEALT14 OF MASSACHUSETTS A,
Board of Health, , MA. p
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed,l ), Repair d ( ), Upgraded Abandoned ( )
at
° has been installed in accordance with the provisions of,310 CMR 15.00 (Title 5) and thea roved design plans/as-built plans relating to
application No. / i 4 y -1 dated - Mrd . Approved Design Flow. (gpd)
r
Installer _t�l_ft_#4o-&.X A. -,-E ���_ /7 n
Designer: Adel -JM AJ! D Sdnl S INC. Inspector: Date:
The issuance of this permit shall not be/construed as a guar411 that the system will function as designed.
No. -150 l4 i) C ' t S `{ l ALL 61 Pe EN iEi le , FEE C)
COMMONWEALTH OF MASSACHUSETTS 7-21
Board of Health, `y MA.
,
DISPOSAL 'STEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) UpgradeAbandon( ) an individual sewage disposal system
at 1? 14 ' N O I& as described in the application for
Disposal System Construction Permit No. ., dated (�
Provided: Construction shall be completed within th C�Fars . the date of this �Per t. All local nditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslmvn, MA Date .'� ' _ Board of Health