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COMMONWEALTH LTH ®F MASSACHUSETTS
Board of Health, AAM007h
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to .Construct( ) Repair(:) Upgrade(u�/Abandon() - ❑ Complete System4191vidual Components:
Location
NA/14 7 .�+ v% a)
Owner's Name
Map/Parcel#Address
Lot#' 3 3
Telephone# 7 — _ 6 Vol/
Installer's Name
ev Ce✓►
Designer's Name S F -
..Address
S _
Address j L.
Telephone#
'7 7 YL
ne# Pj - s- 69(j
Type .of Buildingrest' d,, Lot Size L `%-ydo ' 1 sq. -ft.
Dwelling - No. ,of Bedrooms Garbage grinder
Otlier -Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided 3lO gpd
Plan: Date O_T�3 o ! A Number of sheets _ Revision Date
Title
Description of Soil(s). 4 n_ /,_)Q , M 4.- ell
Soil Evaluator Form No. Name, of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR AI TERATIONS �1' F N hjc^ &e Std a Leoni f^ p�' � _�i� S 4 � �
l cin / 1,-rsi+u� /GY.v�ol• S'
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 Cympliapce has been issued by the Board of Health.
Signed /'--�� Date
Inspections
No.
660 V -19--`c J 7� FEE 4 C
COMMONWEALTH OF MASSACHUSETTS
Board of Health; I A'leWd I V , MA.
CERTIFICATE Of COMPLIANCE
Description.of Work: 'individual Component(,) O Complete System
The undersigned herebycertifythat the Sewage Disposal System; Constructed Os Repaired ( ), Upgraded � Abandoned
by: 1(6_ <<,. d(t ,_S/ r), �
e _ 11_
at Q,%;
has been installed i acco da ce with the roVisions of 10 CMR 15.00 (Title 5) and the ap ed design
application No. y - dated . Approved Design ow • 21 pd)
Installer /? ' cr''"' -C1� `_ %✓ � / E•
Designer: -S Inspector:' 'tr ! Date:
The issuance of this permit. shall not be construed as a guarantee that the system will function as designed.
No. owDc 7
COMMONWEALTH Of MASSACHUSETTS
Board of Health, YA-Aft 0+T�"
DISPOSAL SYSTEM STEM CONSTRUCTION- HERMIT
FEE`S•
clot-! I
Permission is hereby granted to;: Construct( ) Repan/Upgrade( ) Abandon( ) an individual sewage disposal system
at f) 9_ ltl� !'nr%t t ,� as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within of the date of this permit, All local conditions must be met:
7
Form 1255 Rev. 5/96: A.M.:Sulkln Co. Chadegown,MA: Date r.. Board of Health