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No. � --0C�7� 'J_C1 R ~ tR 00ZOgI FE.E'�W
';7_7 COMMONWEALTH OF MA S" ACHUSETTS
Board of llealth, �C Moc&\ MA. 4
APPLICATION FORDISPOSAL SYSTEMCONS UCTION PERMIT
Application for a Permit to Construct( ) RepairJtKUpgrade( ) Abandon( ) Complete System ❑ Individual Components
Location q 9 3 R-1G Z. 8
Owner's Name Howard, .rrl
Map/Parcel# Z - q y
Address 9 !3 - 91S t; Z$
Lot#
Telephone#
Installer's Name 3 4e B E'X(20x0<)' t10
Designer's Name VG
Address
147-c�aSccr LVJ oresi �a c
Address
Telephone# Sog. qvjr)�,5
Telephone#
Type of Building 1 t l Lot Size sq. ft.
Dwelling - No. of Bedrooms Z Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 4W Z2 gpd Calculated design flow Design flow provided 3149 gpd
Plan: Date f O - 1 - 119 Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS ORALTERATIONS TrA1J J'�
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 �t� Date 'S "4$
Inspections
No. C t `; • ' FEE? ,
C®MMONW �.T14 Off' MASSAC� � ��
Board of Health, YIrry10041
CERTIFICATE OF COMPLIANCE
Description of Work:, El Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal_ System; Constructed O, Repaired (w<, Upgraded ( ), Abandoned ( )
by: l C'
at
has been installed in accordance with the provisions of 10 CMR 15.00 (Title 5) and the proved design plans/as-built plans relating to
application No.. : dated l i '!�i ; . Approved Design Flow (gpd).
e
Installer 1 r -IR x C'::.:s t..lc-a'A_ ;_C)J-�4'
Designer: .J A k) r_ Inspector: ` ! _C4 ,en%/ Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. '
No.�it s '� ;J tjs» �� n� [7 d•� FEEuC�
; COMMON LTH Off' MASSACHUS ETT�
Board of Health, k' 7f-PI c.�( ,A k, , Nm.
DISPOSAL SYSTEM C®NSTRUCTI®N KRMIT
Permission is hereby granted to;, .Construct( ) Repair( Upgrade( ) Abandon( ) an indh idual;,sewage disposal system
at % 21c, 17-3 -- as described in. the application for
Disposal System Construction Permit No. (7, dated 9/d
Provided: Construction shall be completed within tf the date of this pert' it. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. ChMestom, MA Date z ' .�� /iBoard of Health
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