App-Permit-ComplianceNo. � 7 � 7 / e 6a&4v�, FEE �� `
�4� vvy� f COMMONWEALTH LTH Of MASSACHUSETTS
YAP�JIOUTH HEALTH D T.
/ j/j/j 65 j�j �� Board of Health, 1146-6-
7 APPLICATION FOP, DISPO9A1y5WEW,M19WUCTION PERMIT
Application for a Permit to Construct( ) Repair Jpgrade OAbandon O - ❑ Complete System ndividual Components
Location v
Owner's Name S
Map/Parcel# 9-
Address
Lot#
Telephone#
Installer's Name v k,L
Designer's Name �--�
Address
Address
Telephone# �� - S��
Telephone#
Type of Building
Dwelling - No. of Bedrooms.
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s)
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size
No. of persons
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Design flow provided gpd
Revision Date
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 to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed
Inspections
N C) ! .2- /
Date
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o. C®I� MON�I, S /_
Board of Health, ya
/- kill�t// , MA.
CERTIFICAA Of COMPLIANCE
Z/ v/ C
Description of Work: individual Component(s) ❑ Complete System �banZoned
The undene hereby certify that the/Sewage Disposal System; Constructed ( ), Repaired.( Upgraded( A ( )
by: /V,G/ �' /
at
has been installed}� accordance with the provisions of �0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No./ "/ dated �/ r ' Approved Design Flow (gpd)
Installer G L/
Designer: --" Inspector: G Date: r
The issuance of this permit shall not be construed as a .-tee at the system will function as designed.
No. 6? - --2 -34- FEE �7 e5 L/
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Con ltruct ( ) Repair�Upgrade ( ) Abandon( ) an indix idual sewage disposal system
at /%/ [)k&r, as described in the application for
Disposal System Construction Permit No./T, 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. Chadeslown, MA Date//- -5e -6 Board of Health
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