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No. FEE
//-/�&e-/COMMONV4AiQ "AjAff"&J�ETTS
% Board of Hea 46 ROUTE 28 MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ). Upgrade( Abandon() - ❑ Complete System � Individual Components
Location /0 O
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Owner's Name Z r,(
Map/Parcel#
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Address I If
Lot#
Telephone#
Installer's Name Al,
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Designer's Name
Address 9 c C
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Address
Telephone# vT C
D- Z
Telephone# �y ��_, Z 9 Z 'Z
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) LZVO gpd Calculated design flow 94M
Plan: Date 1 Z l o Number of sheets /
Design flow provided s i 91 gpd
Revision Date
Title
Description of Soil(s) .ram' N &64 s
Soil Evaluator Form No. Name of Soil Evaluator 40. Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above describe4Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to, place the teem in operation until a Certificate of Compliarice has been issued by the Board of Health.
Signed Date 3- Z-
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A e
Inspections
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No. Q 7, FEE e� .
COMMONWEALTH OF MASSAC� USETT S
"'Board of Health, C%L 4
MA.
CERTIFICATE Of COMPLIANCE
�// n ❑ Complete System
Description of Work: iYlnchvidual Component(s) t(s) p ys 1
The undersigned hereby jertify that the SewageDisposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned(
1) I
at
has been installed in acco a e with the provisions of 3UCMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. �` dated 3 ln �� ./Approved Design Flow!%, /(gpd)
t
Installer /t4, E' R,r��7. __ A
Designer: r ef 4 , / " ' C e-el% Inspector:: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
COMMONWEALTH OF MASSAC14USETTS
Board of Health, (4- / r' / , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct ( ) Repair ( vy Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
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Disposal System Construction Permit o. d %',-7 ^ , dated -3 26 0,
as described in the application for
Provided: Construction shall be completed within 4W4, -e the date of thi�sp e, it.. All local con itions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date -5--)4-6 -7Board of Health
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