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27—
No. o V � 7 FEE66-6
-.Z COMMONWEALTH OF MASSAC14US TTS
Board of Health, MA. 13Z /31)? �C?C7pZ�
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION P ^I�MIT
O
Application fora Permit to Construct( ) Repair( ) Upgrade Abandon - Ll Complete System Individual Components
Location r+h U r
Owner's Name ed lk2J4 -to
; /(f !{ pa_(e q,5Address
15 :4r or LN _
Lot#
Telephone# 50f-&lLam,
Installer's Name t Q
Designer's `NameD,60 f
Address/ L4aba
Address �. 5an ailch A
Telephone# 6 D a - 4-7-7'-/)d 5-3
Telephone# -50q .3--R-13 7
Type of Building 7� PS %� lf% Lot Size �o Jp) �' _"r
Dwelling - No. of Bedrooms _� Garbage grinder {
Other - Type of Building No. of persons Showers O, Cafeteria ( )
Other Fixtures
Design Flow (min, required) 33 gpd Calculated design flow � Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of goil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
Theundersign agrees to install 't ie above described Individual Sewage Disposal System in accordance with the provisions. of T= 5 and
further afire s t ;noX place in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date 'k
Inspections
No. ? "�k11 �"'��Ci FEE ,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ,
,CERTIFICATE OF COMPLIANCE
System tion of Work: _215idividual Component(s)❑ Complete
The -juju ersi teed he certify that the Sewage Disposal System; Constructed,( ), Repaired ( ), Upgraded,�bandoned ( )°
F
by: {�'
!r'. } t�
at ! } �.
has been installed in accordavlce with the provisions of 31.0 CM 15.00 (Title 5) an� �yy,�j�ppyoved design plans/as,-built plans relating to
.. ... J '7-. --,,& /_ P /.a. 1 "9_._ r 7 , — ,"., _ n`I�yC `^7 � � a /
Installer 1 �• -
Designer:C3 / spector: L/e Date: .i -
The issuance of this permit; shall not be .construed as a guarantee that the system will function as designed.
No. ( 1 ; int, "" e f ','(r....+c�".i fjf FEEL) f
17-2 f COMMONWEALTH Of MASSACHUSETTS
Board of Health, Y Ya mo ow MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 1 �A r` as described in the application for
�: ,dated.,
Disposal System Construction Permit No. ,
Provided: Construction shall be completed within A.isee rs o t elte of this perm' All local conditi s must be;met
/�
Form 1255 Rev. 5/96 A,M,Sulkin Co: Chadestown, MA Date
rj i w' R Board of Health f -�