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- � �� ZION �F®� D��P®SAS ��'����'1[ ��������®N PERMIT
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Application for a Permit to Construct( ) Repair (64- Upgrade (14 Abandon() ❑ Complete System Individual Components
Location , , t
Owner's Name
Map/Parcel# G' -. (
Address
Lot#
Telephone# St,�
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Installer's Name `'
Designer's Name
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Address,n`v w y�
Address C), AO
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Telephone# , -off%�%f�..n J/i
Telephone#
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Type of Building�/'o.. aS�. Lot Size �, �3 �' sq. ft.
Dwelling - No. of Bedrooms :AA &-6 Garbage grinder (14 0
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) //0 gpd Calculated design flow 330 Design flow provided n3G gpd
Plan: Date f a -- g- c2 ,n / ! % Number of sheets Revision Date
Title
1
Description of Soil (s) (!p 2 n Sf &A-0'5 6 "d ', a 6 f7o U .3RZ J AQ 'G CoA.G 56:%4 a,� �
Soil Evaluator Form No. Name of Soil Evaluator MA)E Date of Evaluation 9 —7 --o7 o/'J
DESCRIPTION OF REPAIRS OR ALTERATIONS i 5Ujd 400-0 Ton CW;Ay f pazdtn xl caAf��
11
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed a Date
Inspections �` �/ 7��0%�
No. 'f �? t1.t
COMMONWIIALTII Of MASSACIIUSETTD�", 00
Board of Health, YAC V4 4, :t y MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ®Individual Component(s) ❑Complete System 04P 4 4?vj
The undersigned hereby certify that the Sewage Disposal System; Constructed, Repaired ( ), Upgraded ((/Abandoned
by: , i c.
at
has been installed i acc,,r l with th pro/y ns °410 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ,„,LL dated I ! 1 .Approve Design Flow 3.3 "`` (gpd)
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Installer •. C, k iw�r
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Designer: —jt -<-c Inspector: Date: �1 "
The issuance of this permit shall not be construed as a antee that the system will function. as
No. k) c " � m% "6 ("3 q -® (-. c FEE .$� 0 O
( "'% f f MASSACHUSETTS
Board of Health, Yd& imn t 1-r MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct() Repair Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 1S" e - 7 k1 WAST 1,I u -t 14 as described in the application for
Disposal System Construction Permit No. / d dated �� f
Provided: Construction shall be completed within thT years o the date of this permit,, l local cond' on ust be met.
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Form 1255 Rev. 5/,96 A.M. Sulkin Co. 60 on, MA at 1 =�1rd �f He21 h / J
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