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17-14 COMMONWEALTH OF MASSAC14USETTS Ck4. 573
Board of Health, �I�vt� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair)(
epair Upgrado,\Abandon( ) - ompiete System ❑ Individual Components
Locatio ,amN
Owner's Name � ko
Map/Parcel#Address
� it R
Lot#
Telephone#
Installer's Name \
Designer's Name 15 i
Address +0 , G�
Address
Telephone# r
Telephone#
Type of Building Lot Size �— sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other Type of Building No. of persons Showers ( ), Cafeteria ( }
Other Fixtures
Design Flow (myy ina xquired) -171d� gpd Calculated design flow �-J (,� Design flow
Plan: Date 1 I Number of sheets Revision Date _
Title
Description of Sbil (s) _
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
0
Date of Evaluation
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire t to place min operation until a Certificateo/f Compliancle has been issued by the Board of Health.
Signed Date /„��� ” l -
"Inspections
S.
No. ^ ud ') C_. ( "7 -. Z.4(o (v { FEE Q
17-16 COMMONWEALTH OF MASSACHUSETTS 5 -7-3 C,
;Board ofHealtla,ry dmoo , MA.
CE IITIFICA 1 F" COMPLIANCE
Description ;of Work; U Individual Component(s) omplete System
The undersi ned hereby certify that the Sewage Disposal System; Constructed O, Repaired , UpgradedAbandoned ( )
by:
at
has been installed in accor ance with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to;
application No. _7r- dated -'' Approved Design Flow --� (gpd) ^�
Installer o , �zyL s s°'° t - _cx., -Re 4 �A�
, m a..pS s �C_�Yl _ �L.f " � -)6.o
Designer:,-51kM 'ly— Inspector: 1 Date: 7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
0Aaj?-0Lk)5 L—}CC A V , FEE
COMMONWEALTH OF MASSACHUSETTS c 5?3( ,
Board of Health, �'("A , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granteedtto; Construct(
( ) Upgrade Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No17— dated . .
Provided: Construction shall be completed within tjb vA4 date of this per it. All local conditions must be met.
Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown, MA Date. J '" oard of Health ' .''