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App-Permit-Compliance
No. © 2— FEE COMM MVAN tlq k�aCEPU 71 i.ETTS / Board of HeROUTE 28 MA. APPLICATION FOP DI P®SA MM �MTRUCTI®N PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(/I/Abandon() - "omplete System ❑ Individual Components Location di Owner's Name � Map/Parcel# fJ%Gj �, �� Address elVe Lot# Telephone# Installer's Name 66 G� Designer's Name Address 07— �� C�,v Address 9Z Telephone# Telephone# —�Ylg6w_ I2pA Type of Building dpi is Cl/,V Lot Size Dwelling - No. of Bedrooms Other - Type of Building sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated dei n flow Design flow provided C7 gpd Plan: Date 1907/ a� i(j Number of sheets ry Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS . si Ile r�12-L/ Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr s to not to lacethe system in opera on until a Certificate of Compliance has been issued by the Board of Health. Signed cgddelz AV- /?- Date 100, Inspections C®MM®NWEALT14 OF MASSACHUSETTS � �Z /Own .7 Board of Health, Al" MG t�T%� MA. CERTIFICATE OF- COMPLIANCE Description of Work: ❑ Individual Component(s) Complete System The undersi ned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ), Upgraded ( ), Abandoned ( ) by: � ,W T" - �1- CU 2 G at X/ 04V01771 _ _ A/PSi Cts` Gtr' has been installed in accordance with the pro st ns of 310 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to 7 application No.6-7— 2-, dated // —D 7 Approved Design Flow � 9� gpd) Installer U .4, t, = 12 " 7 7 Designer: ��ylf SVS �/� vi G Inspector: Date: / r� The issuance of this permit shall not be construed as a guarante that the system will function as designed. No. �� /'^ FEE COMMONWEALT14 OF MASSACHUSETTS Board of Health, VCel o- I dLJ%7 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to• construct( at (�t1� at A101 i/� /u4G� Repair( &-< Upgrade ( ) Abandon( ) an individual sewage disposal system /� �7 as described in the application for Disposal System Construction Permit No. Q �, dateed /,2 G/ /. Provided: Construction shall be completed within .. are of the date of thisIL" All local conditions must be met. `O Board of Health Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date %I(� C/ ( /