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No. FEE So
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, /�/ MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(*pgradeO Abandon( ❑ Complete System �dividual Components
Location 70 U/#/TZ oC+ k- &I "�,j X
Owner's Name 'I O Ae 6f R F- T A/
Map/Parcel# Sy
Address Q (,v /��%�`£ G CA, 12i�
Lot#
Telephone# jd $ V31 -�L O F3
Installer's Name (` 14 p c o
Designer's Name
Address 3 50 s 1- w v �X-
Address
Telephone# 15-01, ?9r g ro o
Telephone#
Type of Building /
Dwelling - No. of Bedrooms _
Other - Type of Building
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
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
/t F pJ-!¢ C 5, `J7 do,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree n
not to place the system ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed A Date
Inspections
1
N,4; 11 L FEE
Board of Health,
/ f J MA.
,
CERTIFICATE Of COMPLIANCE
Description of Work: 0'rndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ),TJpgraded ( ), Abandoned ( )
by: -A �a Pgp(,
at T-, Q W. 41 %L / Q
has been installed in accordance with the provisiorp of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �s�� dated to / Y (c Approved Design Flow (gpd)
Installer C b !✓� �%
Designer: Inspector: t' r e't / w3 h Date: 7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. `� 0� FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, -Ywx MA. t
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair (&''Upgrade ( ) Abandon ( ) an individual sewage disposal system
at FO 1* #11-1 /' oC 64"as described in th application for
Disposal System Construction Permit No.G?�/ `�C- dated /1"1 -I?? �( (/1
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date/011 &/C? Board of Heal
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