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LlCOMMONWEALTH OF MASSACHUSETTS
�^ j , e l Board of Health, YeA C1'tia J �"'^ , MA. Xlc5l
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT �
Application for a Permit to Construct( ) Repair(,) Upgrade6�L AbandonO 0 Complete System iUndividual Components
Location 56
Owner's Name (JR_ten. ls4 V --x
Map/Parcel#
Address Ica '3` remt.. t`'�tc-
Lot#
Telephone#
Installer's Name r%, A,
Designer's Name
Address1k AA
e�h�N
Address 12 leJ , Csass�t
Telephone#j c-�F - e{QQ =%t 5;z'k d Zfc,3
Telephone# SCIF 1�_ - _ \ Cl'Z.,(e 1-1
k,
Type of Buildings �^ .�i� l — S �'-t�i''�` �� Lot Size -1 Z/ ' ! -._sq. ft.
Dwelling - No. of Bedrooms '� Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 33 y gpd Calculated design flow 73 3 Q Design flow provided 3 Ci gpd
Plan; Date Number of sheets Revision Date
Title 40a 3-. ` �� 6%j-rY\,-,
Description of Soil (s) ® -- -3.d tSANS
Soil Evaluator Form No. Name of Soil Evaluator ik&-11^1 Date of Evaluation 1(
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with theprovisions of TITLE 5 and
further a of to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date �'� �•'i�
Inspections
FEE-
COMMONWEALTH Of MASSACHUSETTS of
Description of Work:
The undersig�ied her
by / s
at
has been installed in
application No`,---A�
Board of Health,cat� ���`�" , MA.
CERTIFICATE Of COMPLIANCE Shh
Individual Component(s) D Complete System �` x
>y c tify that the Sewage Disposal System; Constructed( ), Repaired ( ),Upgraded abandoned
with the provisions of 31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to,
dated I PApproved Design Flow � � �i � bpd)
- nsta er - �✓/
Designer: i / hector. a` / Date:`
The issuance of this permit sh not be construed as a,guawl&e that the system will function as designed. -
FEEZev �{ � {W� a�
V
Board of Health, yc\- 1:n,C1,C"
DISPOSAL SYSTEM CONSTRUCTION' PERMIT
Permission is hereby granted to; .Construct( ) Repair( ) Upgrad& j— Abandon ( ) an individual sewage disposal system
at ` s Q, Cr, kyz LQ r (-A i .-in as described in the application for
Disposal System ConstructionPermit No.AO i2' r , dated,
Provided: Construction shall be completed within ars of the date of this permit. All local conditions must be met.
Form 1255 Rev. 6196 A.M. Sulkin Co. Chadeslown, MA Date f Board of Health