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No. ��/7ad/tTyj36 FEE'V�7�� ,.
COMMONWEALTH OF MASSACHUSETTS
Board of1lealth, VAM.OI_k _VA - , MA.
l etoy ,
xPPLICATIONfT
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( �teomplete System Individual Components
Location 3
Av,4,cA A
Owner's Name a ✓ A bCy /4
Map/Parcel#
—
Address e�.771�.,d LrnC
Lot# 3S
Telephone#
Installer's Name
1l•� L�
Designer'sName
Address 170
X 7)1
Address
Telephone# SO&— 73 1-7- h, 1763
Telephone#
Type of Building its► n k Lot Size '1 16 & 7, sq. £t;
Dwelling - No. of Bedrooms i•..✓" Garbage grinder ( )
Other - Tvpe of Building No. of persons Showers O, Cafeteria
_ -1 _
Other Fixtures
Design Flow (min. equired) 41 C
Plan: Date G 7 6
gpd Calculated design flow _ LJ Design flow provide gpd
Number of sheets Revision Date
Title
Description of Soil (s) d-
Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS y^S� I1 ^/I%�J �c�(c.,,,
S: ,S �u r.<tS S l- c- JeAA
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Ympliance has been issued by the Board of Health.
Signed Date Q
• y 1 L'i/dl�afLL1 / e L`�/ 1 �' 1 �%/�L`�^Lit l� J/
Qu a 45—
No.14
s
�� � -COMMONWEALTH OF. MASSACHUSETTS
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Board of Health, y1d=j Q1_T\A' " MA. �iFi /
CERTIFICATE OF COMPLIANCE
Description of Work:: individual Component(s) ❑ Complete System
The,undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), pgrade �„1,�4bandoned ( )'
at_�„,ic l �,•
has been installed in ccordanc,,with the provisions of 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relati to
application No. __tV s �� dated /• - . Approved Design Flow O (gpd) �" f/ �dfJ� e_1'
Installer li . e5z
Designer: 5,-e,.71SC Inspector:. Date:
The issuance of this permit shall not be construed as a guayantee that'the system will function as designed.
l / COMMONWEALTH MONWEALTH OF MASSACHHUS ETTS
Board of Health, `�_lft:A , MA.
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
FEE �T )
car 77 c` .
Permission is hereby granted to; C nstruct( ) Repair( ) Upgrade(Abandon ( ) an individual, sewage disposal system
at K'< L C, &--b6c-'" L as described in the application for
Disposal System Construction Permit No. / i �!'' dated
Provided: Construction shall be completed within three years of the date of this permit; .All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown-,•M�A Date 1�) Board of Health __/,
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