App-Permit-ComplianceNo. 1[$wyC—IE-2-9314 kJL_,jD / R' / 6__ FEE56"60
COMMONWEALTH OF MASSACHUSETTS 04,* (0CM
Board ofllealth, �V./i'1(1C1i # MA. Wd(l
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct( ) Repair( ) UpgradeAbandon( ) - ❑ Complete Systemd vidual Components
Location
Owner's Name
Map/Parcel#
Address �� r
Lot#
Telephone# 7.7tf�-71—
Installer's Name
Designer's Name
Address '36 ete��
Address PO:5;p
Telephone# 3 ZZ
Telephone#�'� --
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) C7 gpd Calculated design flow Design flow provided - gPd
Plan: Date Number of sheets Revision Date
Title
Description of 5'oil(s) �-Ad—Ae
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
I
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 ague to not to lace the system m opera ' n until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ti le
Inspec
No. t� � " t " . 53FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health, \1AY4M6rJ I +
CERTIFICATE OF COMP.LIANCE4.r ,
:Description of Work:. "®^Wdividual Component(s) ❑Complete System.
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned O`
,
by:
at, C654
has been installed ii cco a ce with the provisions of 31 CMR 150 (Title 5) and the approved design plans/as-built plans relating to
application No. dated :Z.
�' VApproved Design Flow 3 � f . (gpd)
.Installer
ti
Designer: t-4
--e nspector: �� 41`�""�� Date:
The issuance of this permit shall not be co trued as a guarantee that the system will function, as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, yjbmli( rn- MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is'herebygranted to;, Construct( ) Repair( ) Upgrade("rAbatdon( ) an individual ewage disposal system
at 4r, 8 i _ l`.. yA as described in the application for
Disposal System Construction Permit No. dad.
Provided: Construction shall be completed within t,ti.Wa44s_rY'"the date of this peri 1 local conditions st be met.
�. f
Form 1255 Rev. 5196 A.M. Sulkin Co. Cha Woven, MA Date � Board of Health