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No / '� i/ U 114 S RCI U 7 sE- 2-n FEE
COMMON'W11 VANNUSETTS
Board of Health, \114 a -M6 U I Q , MA.
APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeN Abandon - N Complete System ❑ Individual Components
Location
",Sl ver
Owner's NameC- Torn WlC
Map/Parcel#
18 H 3J
Address q j eS V q..
Lot# J
Telephone# bj -- Z 92 3 02- v78 S
Installer's Name
� �"
Designer's Name ROW j
Address CP)
Address2-15cg"
Telephone# W 02 E,-'f�
Telephone#Cj .- -7 7 '7o p
Type of Building D` --,e Lf t e Lot Size sq. ft.
Dwelling - No. of Bedrooms 3 Garbage grinder
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures /
Design Flow (min. required) 33 ngpd Calculated design flow 3745 Design flow provided J7 gpd
Plan: Date 6 lj 1 f Cf ? Number of sheets Revision Date
Title S 1-n PI y.-• P71 uG —FA ✓n W G
Description of Soil(s) Fri Ne 5 t1 " '�/� 1-4 0P cl-7
Soil Evaluator Form No. Name of Soil Evaluator K.J. t Ar� 1liiL Date of Evaluation zJ��-ICt7
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 t in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed laf] L44 Date
No. Ji�U FEE
COMMONWEALTH OF MASSACHUSETTS
l F� tzm b �m4 MA. Cu �GJ
Board of Health, - II
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ,E Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned
by: 612/177-L/
at 15 Si IUP►-i,PA i AxJ yA✓V1nelJ77%
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. r 1 j�Q da/teed 7'-21` Approved Design Flow �%� (gpd)
Installer dJ s �r�/ )-515 f r
��f Lf!/��-- Ins `o f ate: -"'/2- -- �7
Designer: Inspector: p
i hg,;ssac;wq#. this:,permit spau not;;pe construes as a gutee that the system ww,runcRon as aeu.
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