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No. o c— {��c�✓
COMMONWEALTH Of MASSACHUSETTS
Board of Health, -)64f-,M 1 Q - MA. �
FEE
a4736 qE5
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon O - ❑ Complete System nvidual Components
Location
�et 1 rC 4 Off/
Owner's Name 109
Vta
L' fI-f
Map/Parcel#
Address
i
S" -t-
Lot#
dy
Telephone# S U&
399
S7/
Installer's Name
]� i 1, Qrz;, -J�4fj CGh y
Designer's Name p Lf hJ&p4e- 01 S--0 r7/r"tom
Address a
)Z h kAr n n /J (
f Address /_7ed
14,�-
ls� 4,
Telephone# T�XTele
hone# e),L�
S
c 3 7
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
DesignFlow(min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
W
gpd Calculated design flow
No. of persons
Lot Size Z9, sq. ft.
Garbage grinder(�J 9
Showers ( ), Cafeteria ( _)
Design flow provided
ision Date
2�3
gpd
Name of Soil Evaluator of Date of Evaluation 5 - f/ --12
DESCRIPTION OF REPAIRS OR ALTERATIONS &e cSe m-lz—
The undersigned agre to ' all the a ove describod Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to to pl ther__-
min r a Certificate of Compliance has been issued by the Board of Health.
Signed / - / Date �5" 0- -,v - / 7
No.�tt C-�%"'�z� FEE 55,00
/7 1
COMMONWEALTH OF MASSACHUSETTS -316 q8
Board of Health, Y�mrn� , Nm,
CERTIFICATE OF COMPLIANCE b6tv
Description of Work: individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded �, Abandoned, ( )
by: )lS—g,''�er• ;�s .-1 C c y, �)- J
at 7�-, l /
has been installed in accor ance with thl provisions of 310 MR 15.00 (Title 5) a the ap ro ed design plans/as-built plans relating to
application No. 4 dated ��=�7Approved Design Flow �pd)
Installer _14.40-
Designer: P (,f 4 /-,3 S A s Inspector: T Date:
The issuance of this permit shall not be construed as a guar tee that the system will function as designed.
No.
-�--C®MMONWEALTII OF MASSACHUSETTS
.h�
Board of Health, _YAJ?�0 iMt , L4.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE X51 070
CAA ?,(4Li 9
Permission is hereby granted to; Construct( ) Repair( ) UpgradeX Abandon( ) an individual sewage disposal system
at 'l14`-' s L C S c'; �,l Ax I , v.,, as described in the application for
Disposal System Construction Permit No.�'- dateyyd����
Provided: Construction shall be completed withit a 'serif ile date of this it. All local coiliditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestown, MA Date �/ 7 Board of Health