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COMMONWEALTH OF MASS C14USETTS
A�44_411pl
Board of Health,
*mo u7w MA. 0 LD i I'--' 1'%"D0Z3Z7I
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construcy(//epair�4 Upgrade( ) Abandon( - &Complete System ❑ Individual Components
Location 42,
Owner's Name a
Map/Parcel# as - 3� 3
Address U'1
Lot# l t/L
Telephone# 61-) � . %2 -24 '-1a/,i
Installer's Name 8040`Gn-Sir
Designer's Name ,41,
Address S S
Address 0 &) .
Telephone# _ •7
Telephone# 523g - 07 - 5-313
Type of Building
Dwelling No, of Bedrooms
Other- Type of Building _
Other Fixtures
Design Flow (mi . re tired) YO gpd
Plan: Dnate._/���N mber of
Title IPA AJC �/Yi7
Description of Soil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Lot Size Le ��-� sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Calculated design flow Design flow
beets 3 __ Revision Date _
Name of Soil Evaluator
Date of Evaluation
4
gpd
The undersigned agrees to ins bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to a yste in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed r Date /-Q t CSP
r
Inspections 14
's
No. I `(.i 1A fi C • ! 6'' 3 .) FEE
I�
COMMONWEALTH OF MASSAC14USETTS
Board of Health, VAEMOOM , MA.
CERTIFICATE Of COMPLIANCE
Description of Work; ❑ Individual Component(s) 60Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (), Repaired (.. ), Upgraded O, Abandoned ( )
at q'9 Ai1li R a 1 �t i Yl l , I% � t , i • `� 3' i' i j`
has been installed in accordance *th the,rovisions of 310 CMk 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No., dated . " Approved Design Flows. . �. gpd)
Installer f �', lam,
r�
QJS
Designer. . ,7, Inspector: ' _ Date:
g G��as46 ��' • 4� ,
The is
of this perinit shall not be construed as a guar tee at the system will function as designed.
No. 1?2() 64 , FEE
„ . 7 COMMONWEALTH OF MASSAC14USETTS
Board of Health, AAW1/14M4 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to;i ConstructO Repair(. , Upgrade( ) Abandon( ) an individual sewage disposal system
`' 1
at C sr� lit 1 of � rA, t1.:1 `� as described in the application for
Disposal System Construction Permit No.
Provided: Construction shall be completed within t rs o e date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board of Health --
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