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No. 6 ri 4PC-[ D�77q f' 1 ��/� � FEE ilk,, ,�
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' Board of Health, li` , MA.
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APPLICATION FOP,DISPOSAL. SYSTEM CONSTRUCTION PERMIT
fora Permit to Construct( ) Repair( ) Upgrade(-. ` bandonO - ❑ Complete System �9dfi'dividual Components
location O
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Owner's Name
Map/Parcel#
.St�
Address Vh C4- S a
Lot#
Telephone# �% 7 V - �j -7&- ,1& J
Installer's Name
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� L �'n v� C .,i YJ�.7`� �
Designer's Name
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Address
P 0
5 a%` -)6 y�� �. 7
Address -)6 3 J ��rtc c�- �G �� pe...4- I�J7�
Telephone#
_rV -,7 94.6
Tel ephone# SU _ � S �, �
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Type of Building .,S+'� �►�.� Lot Size �.�. 7 �a 7 sq. ft..
Dwelling - No. of Bedrooms - -7h1 PC Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures /�
Design Flow (min. re u. e) �3 V gpd Calculated design flow 35 Design flow provided 3�� gpd
Plan: Date .� U Number of sheets Revision Date
Title
Description of Soil (s) -f S'e
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS � Sf. ( i, , S 7��crsl•t� lox
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 lace the system in operation until a Certificate of Com iance has been issued by the Board of Health.
Signed �� Date—
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No. 1�C`�{�j(-r' �"-' % jet,/• -Z°�d% Wf ��FEE
C®I�IMONW LJT14 OF MASSACHUSETTS d
Board of Health, Y ��11�1�1} , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: odividual Component(s) O Complete System
The unders�ixgned hereby certify that
/the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded (-rAbandoned ( )'
by:
at
has been installed ,{in ac pxdance with the rovisiQns of 31, CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. _ �,�' dated -' . Approved Design Flow _ 3 L� t�i) d
Installer. ',%.
Designer: f v.,e, kf -0 -- - Inspector: _ rz� Date:
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The issuance of this permit shall not be construed as a, guarantee that a system will function as designed.
FEE�t�,
' 6 � COMMONWEALTH Of MASSACHUSETTS
Board of Health, 'VIQ Q 1 _t - , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repai ' Upgrade,( ) Abandon( ) an individual sewage disposal system
at - -1 /> 6 /`s: _ as described in. the application for
Disposal System Construction Permit No % dated
Provided: Construction shall be completed within � _ rs of the date of this pe it. All local conditions must be;met.
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Form7255 Rev.5/96 A,M.SulkinCo. ChaBeslown,MA Dat 1 �� Board of Health '