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C ON ALT11 Obi' MASSACHUSETTS �6 82Z
L Board of Health, _ � MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(VrRepair( ) Upgrade( ) Abandon( ) - OcComplete System ❑ Individual Components
Location
Owner's Name
Map/Parcel#
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D'10- 4-7
Address
Lot#'L-5
Telephone#
Installer's Name /4, 0 k , 17o
Designer's Name A>0 , t e
Address
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Address 14/ 11-40VIII
Vl
Telephone#
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Telephone# 7 S— _ 9 704---)
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) 5~' �y gpd Calculated design flow Design flow provided gpd
Plan: Date 1Zd a Number of sheets % Revision Date
Title
Description of Soil (s)
0
Soil Evaluator Form No. Name of:Soil EvaluatorctL �� Date of Evaluation 7 ^ S
DESCRIPTION OF REPAIRS OR ALTERATIONS a6 e
The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the ssyssttem, in operation until;a Certificate of Compliance has been issued by the Board of Health.
Signed sw/��/ Date
tD iq- - -71611C
No. �;� - Qq --33o ((� �T p� 7f ,{� }� j" " E �.1 L7.6 0
COMMONW LT14 OF MASSACHUSETTS
-(0 Bch c�-
Board of He¶alAth,—r o t , i�
CERTIFICATE Off' COMPLIANCE-?-. s����
Description of Work: 0 Individual Component(s) u/clrnplete System
The undersigned hereby certify that the Sewage Disposal Syste ; Constructed O, Repaired ( ), Upgraded bandoned
by: ! 1..
at Z � t✓da Z--, '
has been installed ] accordance with the provisions 31`0 CMR 15.00 (Title 5) and the ap oved design plans/as-built plans relating to
application No. iC 1 .G dated Approved Design Flow (gpd)
Installer / i e- /- 14
Designer: R, G C .� la/ Inspector: (h�, Date:
The'issuance of this permit;shall not be construed as a ar tee that the system will function as designed.
No.�FEE���
COMMONWEALT14 Of ASSACIIUSETTS - (09z2.-
.Board ofHealth, �f-MWr - ,.MA:.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(( t, )// Repair( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at �i �G6., �,oL�yZ, La/ as described in the application for
Disposal System Construction Permit Noll-- Lam-., dated 2 "
Provided: Construction shall be completed within three years of the date of this per 't. All local conditions must be ;met:.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chabstown, MA Date 7-1) — (a71 Board of Health /