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COM[��ON � 0F MASSACHfJ TTS �`���'cf` coo '`#��-
Board of Health, weer ,^W-0 MA. 65W 14? 1
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(e/Upgrade() Abandon() ❑ Complete System ❑ Individual Components
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Location
Owner's Name aa-ci,-.../ Gv�ir'�tr o�'G
Map/Parcel# 3'�� '�s
Address
Lot#
Telephone#
Installer's Name , ��� `-
Designer's Name
Address
Address
Telephone#
Telephone#
Type of Building 45L cv .�, Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Design flow provided
Revision Date
Date of Evaluation
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 , Date
Inspections
No. Q i� C "��i rJ (�-� .} x; . FEE .
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA. 'to ply/ t' f� .
CERTIFICATE 0f :COQ' PLIANCE Arov
Description of Work: &ndividual Component(s) ❑ Complete System
The undersigned hereby certi5othat the Sewage Disposal System; Constructed ( ), Repaired (t�Upgraded ( ); Abandoned ( )
by: Z rs
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has been installed in accordance with the Drovisigns of 310 CMR 15.00 (Title 5) and the approveddesign plans/as-built plans relating to
application No. /-7– 4-/ 0 , dated — –/7. Approved Design Flow -1 (gpd)
Installer
Designer: Inspector: A,/( U Date: I d•L
The issuance of this permit shall not be construed as a guar&6' that the system will function as designed.
No. CH 3)C . 17-0 1 Z CAP& CO SGPT l C 5MVK-:�5 FEE
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/ D CO WEA Of MASSACHUSETTS 4 �° �
Board of Health, a^i oY`% MA.
DISPOSAL: SYSTEM CONSTRUCTION PERMIT
is herebygranted to; Construct( ) Repair (--rUpgrade ( ) Abandon( ) an individual sewage disposal system
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Disposal System Construction Permit No. 17"' dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
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Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �rje / Board of Health
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