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COM NW LT11®f MASSACHUSETTS
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` Board of Health, N o1n+ , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repaire Upgrade( ) Abandon( ) - ❑ Complete System /Individual Components
Location V3
Owner's Name 8 n'cu1 6r L(.
Map/Parcel#Address3/jo
6h;t sC
Lot#; ) 3
Telephone# 9123 _ % _ J'6
Installer's Name
►C Designer's Nameatpfn 01" e
AddressS'
Address 1�°! _ 2�
Telephone#_
Telephone# ® 3(,� _ S
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building No. of persons
Lot Size %tea aCo %� � sq. ft
Garbage grinder ( )
Showers ( ), Cafeteria { ).
Other Fixtures
Design Flow (min. required) J30 gpd Calculated design flow 3 F� 1%d Design flow provided 33(0 gpd
Plan: Date 'b` OJY—k A -�Lo Ile Number of sheets � Revision Date '1141 -A a6, -20 1 E
Title Ti 4 i a�, 'j- 19 'so Q242, [Aix noe- l.t�ec4 lte�l�rEX.i� h , ►rVl1�
Description of Soil(s),, :5oo 4
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install a ov escribed Individual' Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to pla ie sys n in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date -----yl,
Inspections
Q
No. `B6� T 1J C -PR -Z,9$5,
-9to/ COMMONWEALTH LTH ®F MASSAC14USETTS
Board of Health;
Description of Work:
The undersigned her
by: 13 v4;I eI eb��s'
at a 'y
has been installed i&
FEE ,5, 00
n IL
X425,2.
CERTIFICATE Of COMPLIANCE
d.Individuai Component(s) ❑ Complete System 4oC
>y rtify that the Sewage Disposal System; Constructed ( ), Repaired We Upgraded ( ), Abandoned
r
Bance with the ovisions of,340 CMR 15.00 (Title 5) an th approved design plans/as-built plans relating to
dated. qq
%� Approved Desitt Flow
Installer or d lout:: s rO OKI PLLAI 1
Designer:n /'6 �CInspector: w Date: 0
The issuance of this -permit shall not be construed as a guarantee that the system willfunction as designed. _ -- -
FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, / A -g -m 0tm " , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; _Construct( ) Repair(A) Upgrade,( ) Abandon( ) an individual; sewage disposal system
at /C .} t`` t y..-''4 as described in. the application for
rte; r^•, ;. ` _
Disposal System Construction Permit No. dated }
Provided: Construction shall be completed within %UFee-years of the date of this pennit.er.All local conditiods must be met.
Form 1255 Rev. 5/96',4,M.Sulkin Go. Chadestown,MA Date I _ - ,l _ i' , Board of Health =. ? r; % F 'Ile