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COMMONWEALTH OF MASSAC14USETTS
1 Boat d of Health Q fl rU MA
[CATION F ISPOSAL SYSTEM CON 1RUCT4
Construct Repair(,) Upgrade( ) Abandon( Complete System
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Location 3 Rom.
Owner's Name
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Map/Parcel# a
Address 3 &
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Telephone#
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nstaller's Name rs =
Designer's Name
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ddress -`
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Address
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elephone#
Telephone#
Type of Building Lot Size sq. ft.
Dwelling- No. of Bedrooms 3 Garbage grinder {
Other - Type of Building No. of persons Showers ( ), Cafeteria
other Fixrru•es
Design Flow (min. re uired) 336 gpd Calculated, design flow -36 Design flow provided gpd
Plait: Wte c�4 / Number of sheets Revision Date a ��
Title FE41AL 0,=011
Description of Soil (s)
Soil Evaluator Form No. Name of SoilEvaluator r Date of Evaluation Vzzll,
DESCRIPTION OF REPAIRS] 12 ALTERATIONS
The under a ees
further a n t
Signed 1
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described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and
operation until a Certificate of om iance has been issued by the Board of Health.
Date
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COMMONWEALT14 OF MASSACHUSETTS
Board of Health, )6qama , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 0 Individual Component(s) f-Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed�4epaired ( ), Upgraded ( ), Abandoned ( )
at
has been insla4d in ccor ance with the provisions of Y 10 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. �, dated e -a � � ' `� A proved Design Flow � (gpd)
Installer /
Designer: n ago Inspector: fi Date;
The issuance of this permit h not be construed as a guar tee that the system will function as designed.
No.: f_� -j t°. .� �`>.-''i FEE
Board of Health, Yagflld MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; Construct(%) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at 5 �° 0 - Rail(- % e/ �_ as described in the application for
Disposal Syste"" Construction Permit No. f� !� dated.,
Provided: Construction shall be completed within tree s o K ate of this permit. 1 ocal conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA e—\ Date
�"` ~ t oard of Health /