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_ Board of Health, l ly 11: AM.
APPLICATION FOP,DISPOSAL SYSTEM CONSTRUCTION PERMIT
A plication fora Permit to Construct( ) Repairx Upgrade( ) Abandon( - ❑ Complete System Individual Components
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Location a s
t✓AL Rj>
Owner's Name -Tp 5c-?{ } (!4FJ2,o
Map/Parcel#
Address a(p EU W. AR,
VAR,
Lot#
Telephone#
Installer's Name
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Designer's Name j
Address !
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Address
Telephone# 5
- - 9-2,77
1 Telephone#
Type of Building Rf^� l7%i 4G)QTt A-C, Lot Size _ _sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers O, 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 Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS RJ S"Z' mil! c ET- -CE G
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed C Date
Inspections
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N C®MMON EALT14 OF MASSACHUSETTS b�
Board of Health, YArgm b tni MA.
CERTIFICATE OF COMPLIANCE
Description of Work: C Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; pConstructed!( )> Repaired ( , Upgraded( ), Abandoned ( )
atOf-
has been installed in accordance with the pri
application No. - / , dated _
s� of �310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
�_. Approved Design Flow " ' (gpd)
Installer A I M f-1 ' 7Q.f' SE'�I A SC3
Designer: AJ/A Inspector:
The issuance of this permit shall not be construed as a guaEo
Date:
s that the system will function as designed.
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% COMMONWEALTH OF MASSACHUSETTS
Board of Health, Y ftg& 0 () T)-� M.
DISPOSAL SYSTEM. CONSTRUCTIONT PERMIT
Permission is hereby granted to; Construct( ) JRepair (X) Upgrade( ) Abandon( ) an individual sewage disposal system
at V W° as described in the application for
Disposal System Construction Permit No. -/ q 6, dated ,
Provided: Construction shall be completed within three years of the date of this pe 71iu>All local conditions st be met.