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Board of llealth, �`� ®t , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ❑ Complete System ` tBlndividual Components.
Location G. ��l`r , ad S
Owner's Name �
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name J(w M >�r
Designer's Name
Address O1 ti (M tit
Address
Telephone# S` d Q(.� rq
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design plow (min. required)
Plan; Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
LotSize sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria
gpd Calculated design flow Design flow provided gpd
Number of sheets Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS��C� _ C�y�I'C T -�LL" Ge6r�-P Vt—L
i14 It y vi c1 �G,� �C (� �� 1,,,�r,, �s,1�-� U b. v g i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to of to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed i Date
Inspections
r�
No.o� i .�� ��� 3 FEE
COMMON", WEALT14 Or. SSA(HUSETTS
Board of Health, f�> � , MA.
CERTIFICATE OF COMPLIANCE y
Description of Work: C4/16rdividual Component(s) ❑ Complete System (%f
The undersigned hereby certify that the Sewage Disposal System; Constructed g y ttfy g p } O, Repaired (v�, Upgraded ( ),Abandoned O:
by: ' V(
at ( r 1=1� , r\ `a r� r \ 1 ri r •ti ,�.,1�� .c r �.ul���.
has been installed in accoLdance with the rovisia of 3 '0 CMR 15.00 (Title 5) and the approved design plans/as-built plans veladnng to
application No. dated �•� Approved Design Flow — (gpd) y
Installer if
Designer: e[ 1/1�. Inspector: 'da' Date: —
The issuance of this permit shall not be construed as a guarant that the system will function as designed.
COMMONWEALTH Of MASSACHUSETTS
Board of Health, V"60114 MA.
DISPOSAL SYSTEM,,,CONSTPUCTIO�T PEPMIT
FEE ` f GO
Permission is hereby granted to;, _Construct( ) Repair(\/ Upgrade( ) Abandon( ) an indhidual,sewage disposal gystem
at { _ t � n tf �.c"�� r'� i.� :!Z& ram, tas described in the application for
Disposal Construction Permit No. '•i6 , dated
Provided: Construction shall be completed within three years of "the date of this pemzf All local cond `ons must be met.
Form 1255. Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date I f 7 3oard of Health %"