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App-Permit-Compliance
No. -6 WDC — 66-z -57, � 'T �`5"� FEE' � COMMONWEALTH OF MASSACHUSETTS Gk# to8o s Af/0 ' Board of Ilealth, 1 am t11.��' , MA. ��� APPLICATION FO DISPOS L SYSTEM CONSTRUCTION �PEI�MIT plication fora Permit to Construct( ) Repair( ) Upgrade Abandon( - ❑ Complete System ndividual Components Location 103 Owner's Name ap/Parcel#�AT 5 Address 1 /j 5 Of 6 LO,./,,011 Q j l Y1 Lot# Telephone# �SCjQj ©-•ag 13b Installer's Namea IZ( � Ak X � ? •� �� Designer's Name Address(1 1`G �i/LiAi U�T V �i�� Address ,_q,3 Telephone# JC Telephone# . (0a 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 (min, required) lid gpd Calculated design flow Design flow provided 3 - g7d Plan: Date Number of sheets Revision Date Title Description of 5°oil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr a to not tMAC= e thperation until a Certificate of Compliance has been issued by the Board of Health. Signed Date7� ' _ v13 No. COMMONWEALT14 OF MASSACHUSETTS Board of Health, , MA. D 9 o% CERTIFICATE Of COMPLIANCE Description of Worlc,:r0"Individual Component(s) ❑ Complete System r %i The undersigned here tt cergtify,thathlre Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( ) by: it k(i 4! (1 l«1 at A r -v _(-W(A dt h L C has been installed it accordance with the provisions of 0 CMR 15.00 (Title 5) and the ap roved design plans/as-built plans relating to application No. dated. I^ "'' r Approved Design Flow s Pd) n _ Installer ! f"A ( Designee: 0 C"�G:i (lt�L4ti n(1 Inspector: ,l. Date: ; The issuance of this permit'shall no�nstrued as a guar tee that the system will function as designed. & FEE IK'` 21 COMMONWEALT14 Of MASSACHUSETTS 8 Board of Healtli,j�j}�j j�_ MA. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is herebygrantedto, Construct( ) Repair( ) Upgradex) at Jr)�t7 4,(�eS K�yo La $u— Abandon( ) an indiyidual sewage.disposal system y� as described°in the application for Disposal System Construction Permit No. If dated ' �t Provided: Construction shall be completed within t4wWo£ the date of this permit. -All local conditions'piust be met. Form 1255 Rev: 5/96 A,M.BulkinCo.ChMestown,MA ate' ' f4Board of Health