App-Permit-ComplianceNo. D� c `' FEE
COMMONWE-YARM UTH
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Board of Health, 1146 ROUTE 28 MA. 7j 6ey
APPLICATION FOR DISPOWT?RNMUCTION PERMIT
Application for a Permit to Construct( ) RepairUpgrade( ) Abandon( ) - ❑ Complete System U/ildividual Components
Location 9
G� A
Owner's Name
Map/Parcel#
7 ,® ����/
Address
Lot#
Telephone#
Installer's Name
/ �v f r
Designer's Name
Address / 9
a -e- �� Le' �� ��
Address U,
Z 5'
14/ 91.VVWff
Telephone#
7�,> - F8% Z
Telephone#
'77 5' -
2702
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size /S td / sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) a-/ 1,/ gpd Calculated design flow -Z/y0 Design flow provided -//1/4/ gpd
Plan: Date 9- 7 ` 4 Number of sheets l Revision Date
Title
Description of Soil(s) J e -c ala,.
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation 7'" fl -yZ
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 p ce the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed % A �/ Date AU- ? / ` IV
Inspections
No. le rod /(�/rTtFEE:.>
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ! MA.
CERTIFICATE Of COMPLIANCE
Description of Work: P4ndividual Component(s) ❑ Complete System
The undersigned hereby certify
/that the Sewa%;e Disposal S stem; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: �� J"c�`71 t fF'd7y'." f'�,17
at 17 /i✓G -.1
has been installe . in accordance with the provisions of 3W CMR 15.00 (Title 5) a e approved design plans/as-built plans relating to
application No. , dated f Q "� .a Approved Design Flow (gpd)
Installer .ti% ; er do,/A
r
Designer: Pa" (/G '114 t Inspector: 6Z �/%%� ~ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
f _
COMMONWEALTH OF MASSAC14US ETTS
FEE ✓ 2ee
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f�yI lex j C
Board o Health, CONSTRUCTION i MA.
T�,
Permission is hereby granted to; Construct(
at 9
Repair(,,) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. 77 �datted
�,�,,,,�•��
Provided: Construction shall be completed within th-xee �earrs'o`t t1 e date of this pe>rimi All local cond�'ons must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date 16 --�'7 Board of Health