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No. E����:�.`�Ei ��i--T.
FIR + , HFEE �
COMMO
v AMAS$ACIIUSETTS
Board of Health, MA. ee�
APPLICATION FOR DISPOSAL SYSTLM CONSTRUCTION PERMIT
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System iIndividual Components
Location
Owner's Name V s 42 "Ll A.y �-
Map/Parcel#
Address S111 4,k
Lot#
Telephone# —d Ve , j
Installer's Name �v t v S f 1/(p l K/
Designer's Name dcl- t
Address
a
5 2 G
Address .�
Telephone#
S& jr (o Z- 3 d 6 d
Telephone#
Type of Building
4-' Lot Size �� G�� sq. ft.
Dwelling - No. of Bedrooms
3 Garbage grinder ( )
Other - Type of Building
No. of persons 4z— Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)
gpd Calculated design flow Design flow provided gpd
Plan: Date 5<p /- 14
226 Number of sheets 3 Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unders' ees to install
the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
to to place
further a ts—t
system in operation until a Certificate of Compliance has been issued by the Board of Health.
. SignedDate
inspections
No. //7 L/
1 k e-, P F FEET
Board of Health, ,,Ji-/4 -/ MA.
CERTIFICATZ04 COMPLIANCE
Description of Work: *UIndividual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (-+, Upgraded ( ), Abandoned ( )
by: .�i� �ri7u� (-2 ^ A?, rV
at 3 F- "' !t> S-i L/G o2 "k .0 U 7%lt !i a2
has been installed in accordance with the provisions of 3x110 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. ® �vdated :1 l Approved Design Flow / (gpd)
Installer !/G /!J S //t
Designer: 4/1/Z/_ A/ Inspector: Date: 5
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, '7'i�i�1 MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( -)- Repair(
at
4- /-9
FEE
Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No., dated 1
Provided: Construction shall be completed within ��f the date of tht. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date I ` Board of Health