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COMMONWEALTH OF MASSACHUS TTS n4c)
Board of Health, MA.
APPLICATION FOR DISPOSAL SYSTEM CANS UCTION PERMIT
Application for a Permit to Construct( )`Repair( ) Upgrade( Abandon( ) - omplete System ❑Individual Components
Location S J CU r U i 'n , Ro
Owner's Name
DmAS
F-i" p—i
Map/Parcel# 5
Address R
i i� M R r9ax-rf.
Lot# �3
Telephone# tQ 1,q--T30--C21WC,1
Installer's Name �-
1' . 1tiier'
Designer'sName
Address O, Q I SY. w 6h g
Address Pr b :$!7&
y S
Telephone# - d. )G-3D
I Telephone#
0
c) W K
Type of Building Lot Size b t 4 G r� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria.{
Other Fixtures
Design Flow (min. required) % 1 gpd Calculated design flow Design flow provided
Plan: Date ��1 ! Number of sheets 3 Revision Date
Title
Description of Soils) _
Soil Evaluator Form No
Name of Soil Evaluator A V 1 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS N s Ice t.000 Q CP 1 0 A) -VA 0d - 6 0 �( . _ (3) So 0
The undersigned agrees to install above described Individual Sewage Disposal System in accordance with the provisions of TrIT E 5 and,
further agrees to not to place ter in operation until a Certificate of Co fiance has been issued by the Board of Health.
Signed Date�a•`�
Inspections
No. 7EE
Board of Health, ice` t" 0 0-n4 MA.
`` CERTIFIC,AT'E OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ®"complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded Abandoned ( )
by. nbv -r '0, P,
at
has been installed in accordan e with the rovisions oJ,310 CMR 15.00 (Title 5) and the aa�p%proved design plans/as-built plans relating to
application No. , dated_. Approved Design Flow 1� Y—(gpd)
Installer v. , � . C)6(Z- i!t_._ _I,_ _C44-2-'isy"rjP% i;-r + Q ok-,m-r .,
Designer: Lis Ltd j R I4F- Ohl r" l Alf.-�kY*nspector:
The issuance of this permit;, shall not be construed as a guara
that the system will -function as designed.
2-14 COMMONWEALTH Of MASSACHUSETTS
Board of Health, A4 (r, )+ MA.
DISPOSAL SYSTFEM C®NSTWCTI®N PERMIT
_ FEE
d&-# 0)
Permission is hereby,granted to;. Construct( ) Repair(
Upgradep Abandon( ) an individual, sewage disposal system
at 'i� c CurUe • H i tV_W as described in. the application for
Disposal System Construction Permit NA -,
Provided: Construction shall be completed within thr4@4Ft date of this permit A1119cal
.c`onditions� st be;met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date i %� Board of Health