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No. �C_� / w�G_I^��D'� 0o2041( FEE' lV�
! % � COMMONWEALTH Of MASSACHUSETTS GQ+66 7
Board of Health, IM (d%� MA.
APPLICATION FOP DISPOSAL. SYSTEM CONSTRUCTION PERMIT.
Application for a Permit to Construct( ) Repair( ) Upgrad AbandonO - ❑ Complete System JQ46dividual Components
Location 42
Owner's NameO yj
Map/Parcel#
Address -"j rpf Z Rh 1 �
A Z
Lot#
Telephone# t� (?q
Installer's Name % -� CX Cu
Designer's Name(
Address j "1
Address JG 0 ll
Telephone#
Telephone#' 1 11
Type of Building � I Cif Lot Size, sq. ft.
Dwelling - No. of Bedrooms- Garbage grinder ( )
Other -Type of Building No. of persons Showers (}, Cafeteria ( ).
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date 11116113 Number of sheets Revision Date
Title
Description of Sbil(s)
Soil Evaluator Form No, Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS -N2-,o d ha -x f2-) -LP,0ch t m,- -T-(-C t7Ch 6
The undersi ed a ees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further,agr_ to place th to era6on until a Certificate of Compliance has been issued by the Board of Health.
Sighed Date
Inspections
No, G'L��`S t fr t. ?-C� FEE �1
,,
COMMONWEALTH Off` �CASSACHUSETTS t� �, oc"o.I
Board of Health, Vmmpum_, MA.
CERTIFICATE OF COMPLIANCE
� f
Description of Work: PIndividuai Component(s) ❑ Complete System
The undersigned hereb "certify that the Sewage Disposal System; Constructed ( ), Repaired (�), Upgraded.(. ;abandoned ( }
at
has been installed in accordange with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application -M-, / ,-„611” dated Approved Design Flow (gpd)
Installer�r' 1
Designer: '' 3> t , 1�.- 'a Inspector: Date:
,.
The issuance of this permit 111 not be construed as a guarafitee that the system will function as designed.
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No.: t° f`i•3 in -� r Si;. 1 i �`�.��'f-f 11dv�S`.3 FEE Trr�.i
_ ,
COMMONWEALTH Of MASSACHUSETTS Cki�(,Cd) -7
Board of I-Iealtla, _-A J? , MA.
DISPOSAL. SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual, sewage disposal system
at: as described in the application for
Disposal System Construction Permit No. �% ''�, dated ��� _/ 7
Provided: Construction shall be completed within tl o_ tl e date of this peri }it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChMestOwn, MA Date /� - � E oard of Health -
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