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COMMONWEALTH Of MASSACHUSETTS
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Board of Health, , M.
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade bandon( - t Complete System ❑ Individual Components
Location IaGOr
Owner's Name ko.)td)eT Lliur".SS- 1/,0Vh-4
Map/Parcel#
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Address I ,
Skore, rX- 531,Nj &662,''h, A4
Lot# L)
Telephone#_°S
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Installer's Name
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, TP G Designer's Name
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Address a
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Address
4JIGS F i ffeNtv)
Telephone# TOE—
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Telephone#
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Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size eoq sq. ft.
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Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures ����•
Design Flow (min. required)
� �t L'�-4D gpd Calculated design flow �� Design flow provided qqo gpd
Plan: Date l 1 t f.o Number of sheets Revision Date
Title
Description of Soil(s) At. -R M► 34 --Aa G hprrt�o y — /ltd) V y)
Soil Evaluator Form No.
Name of Soil Evaluator A'"NI 95ffl Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 U t N I V rk> 11 cv U— C -j
The undersigned agrees to install the abovetilescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to the syste eration until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ( l�b i
Inspections
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COMMONWEALTH Of M ASSACIIUSETTS
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Board of Health, R-9 6 UTV , AIA:
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CERTIFICATE Of COMPLIANCE � ;-4.� � � ;;E It jr�
Description of Work: ❑ Individual Component(s)ir <0i plete System
The undersigned hereby certit� that the Sewage Disposal System; Constructed (' ), Repaired ( ), Upgraded�Abandoned ( )
by:
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has been installed ina ccorda e—writh the ovist s of 3],0. CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. 16 -)- ,/dated '/Approved Design Flowj? � 1 �+----(gpd)
Installer .E 1- 1 1 u F�'lr�YZ C� t) i� / 1 kzl, Ni
Designer: �2- I Vcj' L� 6 � � Inspector: ` _Date: . 4Z&
Theyissuance of thLs pgrmit shall nQ �e construed as a guarantee thatthe system will function as designed.
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COMMONWEALTH ®r MASSACHUSETTS�07J-�
Board of Health, ���z/%ab In14-
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade.(.�Abandon( ) an individual sewage disposal system
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as described in the application for
Disposal System Construction Permit No./ � dated
011
Provided: Construction shall be completed within tlrree�years"of the date of this permit. - cal condition&_ ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadesiown, MA Date `� f� — pard of.Health