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olNo. / y V _ FEE
Board of Health, 1146 ROUTE 28UQ
PP�.ICTI®N . R. DISPOSAL SYSTEM ��NATRUCTI®N PEI�l�[IT
Application for a Permit to Construct( Repair( ) Upgrade() Abandon( ) - Complete System ❑ Individual Components
Location 22 0- q n r
Owner's Name LcnnL4 L®z.i
Map/Parcel# Z (O 3J
Address
Lot# 3 C0
Telephone#
Installer's Name %
14 Designer's Name
Addresf L3V a HAL
Addres
Telephone# (Aj - rZt
Telephone# --
Type of Building �a�5 .� -c�� Lot Size [q . !Ljq- sq. ft.
Dwelling - No. of Bedrooms IGarbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) WOO gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets 2 Revision Date 7
Title I
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator �nr�� , teff Date of Evaluation
DESCRIPTION OF REPAIRS
—In IXee-L-;l,.•J..w,n 1 .sv`. 1.f_,1A n^, /2) %n!i..X —AL.,. , I-A1YW
a 10120 C-Aj5b ni cis 14 nQSGa�Q 1, ddu a..4, user obin .
The undersigned agrees t install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not t lace tem in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed , Date
Inspections
No. /' - -.. f EE
COMMONWEALT14 Of MASSACHUSAT
Board of Health, Vjw MA.
r.
CERTIEIC E COMPLIANCE
Description of Work: 0 Individual Component(s) 0 Go&plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (�Repaired ( ), Upgraded ( ), Abandoned ( )
at n �/ .` 1 , -.�ee
has been installed in accordance with tV provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. f7 dated �_ , -� Approved Design Flow(gpd)
Installer � 1
Designer: - Inspector: / j / / AQ& Date: --h I "7
The issuance of this permit shall x(ot be construed as a guaranteeffiat the system will function as designed.
No. 17' 4`ld� /�� FEE V 4'
/ C®�'IMO 1II ®'MAS ACIIU ETT -
Board ofHealth, X4. MA.
DISPOSAL SYSTa CONSTRUCTION PERMIT
Permission is hereby granted to; Construct�Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No.' 14'dated
Provided: Construction shall be completed within thre^dW }i 'the date of this permit. All local conditions must be met.
Date - --
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestowq Mn .1 ,- Board of Health