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No. WgiOC-I V' W/�"L8r DoggO?j FEE—42;:00
00
CO1�'1 MONWE ALTH Off' MASSACHUSETTS�4(2%
Board of Health, kffioxy , MA. ao
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(✓r Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location (M
Owner's Name GU\
Ares
Map/Parcel# t -
Address 4"A C, %
Lot# k l�
Telephone#
Installer's Name �
Designer's Name w .
\Ac\G\
Address
Address �o-
.
Telephone# ��^h�
Telephone# Q D-
Cb U
Type of Building ! Lot Size &S-60 sq. ft.
Dwelling - No. of Bedrooms eL Garbage grinder (40
Other - Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) �� gpd Calculated design flow Design flow provided � 9 gpd
Plan: Date tog Number of sheets Revision Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS M t2 1410 C k&PA &" G-kG r%C.–
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further allrpes to not to 1 ace th tem in operation until a Certificate of `Comjpliance has been issued by the Board of Health.
21-k--.0
-�
Signed Date c'1 1 -- 1
Inspections
No. �d4i .. [ "1 FEE
COMMONWEALT14 OF MASSACHUSETTS -12
Board of Health, MA. j
CERTIFICATE OF COMPLIANCE
Description of Work: Qndividual Component(s) O Complete Systema
The undersigned hereby certify that the Sewage Disposal System Constructed( ), Repaired V, Upgraded( ), Abandoned ( )
by:
at t.= Mr- N(� to^1r `/4 CMUy 0 0\
has been installed 'A accordance with the
application�No. 3t —6 .� dated
Installer Y ; M tr- r'C44\, VC
) CMR 15.00 (Title 5) and the approved design plans/as-built,plaris relating to
Approved Design Flow _(gpd)
Designer: \s n c ,c tA ; u4 Inspector: "( l/f `ij f J �° Date: _
The issuance of this permit shall not be construed as a guaante:that the system willfunction as designed.
No.l t� iJ t ti k � -"� a� � F� F)f FEE $5-5 100
f =,
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YOM 0 U -M MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an indiv=idual sewage disposal system
at 'li A-\kar C N as described in the application for
Disposal System Construction Permit No., dated.
Provided: Construction shall be completed within th 'fs oT the date of this permit. All local condtio . must be met.
Form 1255 Rev. 5/96 A.M. SWkin Co. Chaqesiown, MA Date �'T,Board of Health