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COMMONWEALTH Of MASSACHUSETTS
FEES O�
"16055
Board of Health, Y IDInM , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for Permit to Construct( ) Repair( ) Upgrad41j'/Abandon( ) Complete System ❑ Individual Components
Location M 9
fl j dAa4Owner's
Name
Map/Parcel# 1254-93C-
Address
Lot#
Telephone#
Installer's Name GIIA& U
Designer's Name &4 lruu -
Address 30 Q� -5
Address Q 6X q Iu0 S f e4tKAS
Telephone# 1
Telephone# . 9
Type of Building I Lot Size sq. ft.
Dwelling - No. of Bedrooms 4 Garbage grinder( )
Other -Type of Building No. of persons Showers( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Steil (s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
i
Design flow provided,T -7 — gpd
Revision Date
Date of Evaluation
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr a to not to place the system ' operation until a Certificate o Compliance has been issued by the Board of Health.
Signed Date
No. 1�, f � � 1� C -- � �- �) U, K'j C:.3 FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, YAL.dVt O T( A , AM 0 I
CERTIFICATE Of COMPLIANCE
Description of Work: C1 Individual Component(s) U elm1 plete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded.( -<Abandoned ( )
at =q� .�( -krrf
has been installed in accord c
application No.
Installer o..d,t3
a,-
Designer:a.tl�-r'.�
The issuance of this permit shd
with the provisions of 310 CMR 15.00 (Title 5) and t proved design plans/as-built plans relating to
dated _Approved Design Flow (gpd)
Date: _ -2- O__
not be construed as a guar&ttee that the system will function as designed.
No.AP1 FEEC?
COMMONWEALTH Of MASSACHUSETTS c.k Ak ion 5
Board of Health,SJAJOMA MA.
DISPOSAL SYSTEM[ CONSTRUCTION HERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (r.•) --'Abandon ( ) an individual sewage disposal system
��1 .1 f
at �- I ` 3I t'"C1 dvatm ��� i CIA Ad as described in the application for
Disposal System Construction Permit No. 1 /t , dated).,�gg nfl
Provided: Construction shall be completed within A s o?the date of thiser i it. All local editions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co.. Chadeslown, MA Date tt - -� oard of Health � .
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