App-Permit-ComplianceNo. $0t0C (S --2y BL TIZ ' 1� (�vGrl� �-) FEEi66"OC)
1 � C" I✓ONWEALT14 Of MASSACHUSETTS ak;OM6-7
Board of Health, U l�' MA.
P C N FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(AbandonO - ❑Complete System ❑Individual Components
Location 5
Owner's Name - _ .K
Map/Parcel#
�3 s
-\/arrvx_
AddressE4 M4 G cL
Lot#
+L
Telephone# Soo » �� : • " I�'1 `7
Installer's Name I, a
��' Designer's Name a 6, end
lYl 1
Address,So
�U " L
6 &)L -J_ Address �� g
Telephone#
36i -
Telephone# \,5016 —A
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) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Sbii (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS!
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire to not to l�ance, thr system jn o eration until a Certificate of om iance has been issued by the Board of `Health.
Signed w f.-� Date 115-118
Inspections — Olt
No
1
CO MONUALTH OF MASSACHUSETTS
Board of Health, YA.02
CERTIFICATE OF COMPLIANCE
Description of Work: O Individual Component(s) O C�nplete System
The u>,dersgned hereby certtfythat the Sewage Disposal System; Constructed O, Repaired ( ), UpgradedAbandoned ( )
at
;.. ;
has been installed i 9accor nce with the provisions of CMR 15 00 (Title 5)j and tti a ved de ign plalis/d built plans relating to
applieatibn'No r" 'fit ;Fated: ~ App�roved�esigiltFlo'iw-gpd) '¢ .. f
Installer 1:1 fel
� • z
Designer: adz`. }i t0 �4" it ' .►.y Inspector: �{ti,; ate:
cl as' a,guarantee that the system will function as designed.
The issuance of tl is permit shallen�"be cio u
No: ,45 ht'awL' !Y i>dP FEE
1
`- COMMONWEALTH Of MASSACHUSETTS
Board of Health,(t�t
DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Permission is hereby granted to Construct() Repair( ) Upgrad Sl) Abandon()an indixidual,sewage disposal system
gg f
at as described in the application for
Disposal System Construction Permit No. Jk-4 , dated
Provided: Construction shall be completed within t4wra e s off the date of this permit. W al conditio s n , st be met.
Form 1255 R11,5/96 A.M. Sulkin Co. Chadeslown, f�1Ati Date -> ' `� ` ! � Board of Healt