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COMMONWEALTH OF MASSAC14USETTS dt*V3
Board of Health,
APPLICATION FOP DISPOSAL SYSTL 9[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (UUUpgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location Z,Z iii/Oi^ /�ipo l[
Owner's Nam ^.,, G
Map/Parcel# dCj�e �j�ej
Address
Lot#
Telephone#
Installer's Name , G
Sc -L' _ie�aYG�
Designer's Name
Address3 % e �
Address / - "010 ,
Telephone# �,��-'
Telephone# 7-,-f/- 3a>- 07'1e3'
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Type of Building Si'
Dwelling - No. of Bedrooms _
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date��S/�2
Title
Description of Soil(s) _
Soil Evaluator Form No
Lot Size
No. of persons
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
gpd Calculated design flow? (:> Design flow provided
)er of sheets Revision Date
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS--.��sf�l� /S'ry Gkl /7�-/0 ,T <' /f -tea
gpd
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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed -C' y ���� / Date 6Z-",3 //7
Inspections
jr[ 'I n
No. I Z( C -I /`""`T- � (� COMMONWEALTH MASSACHUSETTS FEE
Board of Health,MA.
-CEPTIFICAT E Of COMPLIANCE
Description of Work: ❑ Individual Component(s) t omplete System
The undersigned hereby certify that th Sewage Disposal System; Constructed ( ), Repaired (--,)-,,,Upgraded ( ), Abandoned ( )
by: �e-/ sus L- ,�'e roc/! Fr'i''rric S' rGi eC;.S'
at f3,r Go
has been installed inacc�jr ance with the provisions of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No. 17 / dated /L / 7. Approved Design Flow (gpd)
Installer'
Designer: t1 1_ �3NS(-&) �F Inspector: n Date:
The issuance of this permit shall not,be, construed' as arguftrantee that the `system will function as designed. "f
No. t� Q µ l� `� - �! C A P C,' C o o'.. � i c' � ��� V i �� FEE S`3 , 6 d
Board of Health; v- orc7i , MA.
r
➢DISPOSAL S YSTEMI;CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 22 m'described in the application for
Disposal System Construction Permit No., dated %�" �d
Provided: Construction shall be completed within s of the date of this per 1 local co itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date, _ T� . f y ?Board of Health_