App-Permit-Compliance,.No.�(j��(` C45 FEE SS, 00
COMMONWEALTH Of MASSACHUSETTS CW 1(4(10
Board of Health, V® o -N , MA.
APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair N<U' pgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location /I, lllo fyo lii ®
Owner's Name MAf4e_
Map/Parcel# V , t
Address & ^V10_4 !? y A4 , S, VC,r4.0v—/I--
Lot#
Telephone# 315"- ii 7Z - q2100
Installer's Name Pohe4-r t
&. _T>7C_ Designer's Name
Address Zq 6 rear WO
1 Address
Telephone# SOF-so
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other. - Type of Building _
Other Fixtures
Design Flow (mina required)
Plait: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of persons Showers( ), Cafeteria ( )
Design flow provided gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS AQ IO~Ce O—BOX , f e_A 6,ce y "Age 1MAA '7-r4nJ
t7urkt: eV b-ByIe -FAX -TV _A -r
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 lgce a system in operatiioon until a Certificate of Compliance
has been issued by the Board of health.
Signed .W � & 2, L�Q'A Date D - � J
Inspections
No. W-1Dc-(Q8 66 5B FEE Aa 60
CON[MONWFALT14 OF MASSACHUSETTS
Board of Health, V AA �, MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ®"Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired (K, ), Abandoned ( )
by: k3 dt- - , wr 6P pnc.
at Its"—fin ma w /
has been installed i accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow (gpd)
Installer
� r
Designer: "" Inspector: ,t ® Date:
The issuance of this permit shall not be construed as a guaratee that the system will function as designed.
rll pp�'� e ? FEE
No. ? ' � �_ 1� —y„! t ,.�'� �t... �� ..o l� � f..r � '�' :i7 v ' 'T LG?
J� . COMMONWEALTH ®L' MASSACHUSETTS c �
Board of Health, V AaN 01 MA.
DISPOSAL SYSTEM CONSTRUCTION IPERMIT
Permission is hereby granted to; Construct( ) Repair (V Upgrade ( ) Abandon ( ) an individual sewage disposal system
at
Disposal System Construction Permit No. / .i, datedS
as described in the application for
Provided: Construction shall be completed within three years of the date of this per.fnit. All local con ons must be met.
�
Form 1255 Rev. 5/96 A.M. Sulkin Co. CMdeslown, MA Dat@�� oard of Health !,r�