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No. Of ✓3 !7�/�,® FEE
COMMONWL%
Board of Health, 114 ROUTE 2u MA.
YARN�S3U� d-I, MA 02664
APPLICATION FOR DISPO�Xl SIYST� CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(�andon( ) - "omplete System ❑ Individual Components
Location �g A� O�Lo♦
Owner's Name ��(. •✓S
Map/Parcel# �/ rf'
Address G /'/
Lot# !
Telephone#
Installer's Name �G �,
Designer's Name •z/ %�%�
Address
Address
Telephone# Sp j:- 7 s
Telephone# j 3
Type of Building /Z g S
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
No. of persons
Lot Size sq. ft.
Garbage grinder
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow 3 S 3 Design flow provided '3-53 gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil (s) /p�� r✓
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
/% 4
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t of to place the cystpain operatio_n until a Certificate of C Ii !!de has been issued by the Board of Health.
,.Signed Date %-
Inspections
No. 09 3 �3 r
®��//�� �TW � 14 F MA S���TTS
1`�ll�®1V` V'V` ����L7t
Board of Health, Y,10,4 1"/r—h , MA.
CERTIFICATE OF COMPLIANCE
FEE
C%-P, Z%
Description of Work: ❑ Individual Component(s) UMomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: ✓L L l
at
has been installed in ac or e with the rovisions o 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to
application No. _��dated Approved Design Flow (gpd)
Installer /V,�)
Designer: 2 �% �� Inspector: Date: /
The issuance of this permits not be construed as a guar ee that a system will function as designed. /i/Pv'
31
SSv P 1o'r
No. _ /J�L�' f ��. FEE
C®�1[I� ONWEA 11 Of �'1 ASSAC14US ETTS cCr, 2i4b
Board of Health, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(- riepair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at ` I ��('�' `O "�'� " as described in the application for
33 Disposal System Construction Permit No. - 3, dated 45�
Provided: Construction shall be completed within t s of the date of this . rm� All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date � �/ � !a Board of Health