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No.
[ 6-00%57
COMMONWEALTH LTH OF MASSACHUSETTS
Board of Health, Yagai2tjn , MA. /> GI
FEE it
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( ) - ❑ Complete System_;-.'individuat Components
Location
— 8 SP" CE- n 7 Owner's Name
Map/Parcel# C�/'�j ��
Address
Lot#
Telephone# do -. Cy, 9 0
Installer's Name 1,
Tt ZJ� 7��(y G Designer's Name E
Address �� �- fr
Address -39 51i
Telephone# 52z- _ y xv _
(® Telephone# -bT 3l -;Z
Type of Building Lot Size f�� ��� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) _330 gpd Calculated design flow Design flow provided 33 -3 gpd
Plan: Date 4 � //��il.� Num
ber of sheets / I, Revision Date
Title '54k
Description of Soils)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agreesAargist-p the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to n to plat the system in operation until a Certificate of Cogipliango has been issued by the Board of Health.
Signed Date !
FEE �° . Q'Q
COMMONWILALT14 OF MASSACHUSETTS
Board of Health, )6 Y o t + , MA.
CERTIFICATE Of COMPLIANCE
Description of Work: individual Component(s) ❑ Complete System i
The undersigned hereby certify that the Sewage Disposal System; Constructed
Repaired/), Upgraded Abandoned
by: 4ivr-6
( )
(rr t ��l`�
ter- ., _ c.�._ f )
at ._� n t" d )r Ski _..� XJt T _ : 1,/') n AIM e",t
has been installe&Td cc'od nce nth th�p�ti s` on of 3 0 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. `t%' ,dated =�a Approved Design Flow (gpd)
r
Installers 6--�
Designer: ,;; y ; �h "n 41 _ Inspector: ' (' � _ Date:
The issuance of this permit sh not be construed as a guaragtec"that the system will function as designed.
No. ,..' C U(U t UTi� FEE `.
�' j I" COMMONWEALTH OF MASSACHUSETTS USETTS ( 11-70
Board of Health, Y4` --"i 6'MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repaii-0 Upgrade( ) Abandon( ) an individual sewage disposal system
at
0
as described in the -application for
Disposal System Construction Permit No. 46 FY dated
Provided: Construction shall be completed wtthtn tears of the date of this permit. AA1 local conditio� lust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestavn,MA DateE Board of Health