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No. FEE
C�ZO�I�
2, CO COMMONWEALTH Off' MASSACHUSETTS
A;P-UXC�Aoard of Health, *tmT" , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade (,4/Abandon ( ) - a'Complete-System O Individual Components
Location e 01-
Owner's Name
Map/Parcel#
Address
Lot#
Telephone#
Installer's Name r I I
Designer's Name %i h pyh
Address f� O1C�'
Address O
Telephone# QaQ a
Telephone# S 7
Type of Building Lot Sizoc��,5.0> 7 • V sq. ft.
Dwelling - No. of Bedrooms L4 A Garbage grinder (V
Other - Type of Building 7 No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided 4�gpd
Plan: Date %a/ 13 _ _ Number, of sheets l Revision Date
Title
Description ofSoil (s) Sal So % Lo- 7:�"M,�,,. r --
Soil Evaluator Form No. Name of Soil Evaluator �Tnbn.� ; a Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
s,
The undersigned agrea(toAnstall the above ribedJntlividual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to the �m ' �xtifa Certificate of-Cornpli 'ice has beenj'Vued by the Board of Health.
Signed Date '� ® / -
^sy ,Inspections_
N
Y `tLOA^L:GVev
HE/aLTH bEPT.
No. ? �-� �- a� FEES
COMMONW]CTH Of MASSACHUSETTS � � � w
Board of Health, &O iM QQ-gV , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: El Individual Component(s) J mplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaiy ed ( ),*Upgraded ( ~bandoned ( )'
has been insta ed in accordance with the provisi�ns of 0 R t15 06 (Title 5) and e ap rived design plans/as-built plans relating to
application No. �" > , dated " %��` of
Design Flow-� )
Installer I c
Designer: -'1 �(a r. ' rl .d !�: �: , L . S Inspector: % !.d :"�' Dater
The issuance of this permit shall not be construed as a guarantee at the system will function as designed.
No., `t: R m FEE6 V
le, -:3- COMMONWEALTH Of MASSACHUSETTS
V 4`
Board of Health,
DISPOSAL SYSTEM CONSTRUCTIO - PERMIT
Permission is hereby t granted to; Construct( ) Repair( ) Upgrade (�---Abandon ( ) an individual sewage disposal system
at i- ri 610"1 f-4-1 -).,1 p C =�L. ,, r. tl zl- e/ d-64 described in the application for
Disposal System Construction Permit No. 02" :72/ dated .12.." / 19/4
Provided: Construction shall be completed within tui.�4�tlie date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A SulkinGo.
Chadeslown A _ Date t Board of He lth