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No. B 6 D C' FEE 0
COMMONWEALTH OF MASSACHUSETTS
Board of Flealth, Y6 !�P OTA IMAe,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCT, N ARMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(�bandon( ') - ❑ Complete System &r,5dividual Components.
Location
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Owner's Name ;-C/i' -e-/ %'J"7 5 J) /' .fie.. G'
Map/Parcel#
G
Address ..5- G£-/ - C7 L., �! /4, I `-
Lot#
Telephone# v>', j ✓ c Wn��" L•
Installer's Name
_,� - r iV�l
Designer's Name
Address-,
'' A
C r ltr�; l
/moo �3 ��C 7
Address S IA�
Telephone#
T C:)
Telephone#
Type of Building .✓?49 ( /yJ YY � �✓ Lot Size _ sq. £t.
Dwelling - No. of Bedrooms Garbage grinder Wv
Other= Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required)y gpd Calculated design flow �� Design flow provided �� gpd
Plan: Date �� tj—Number of sheets - Revision Date
Title Pi� C- t ;A rS
Description of Soil(s) S Sri i 1 y
I G� Date of Evaluation
Soil Evaluator Form No. Name of Soil Evaluator ` y S
DESCRIPTION OF REPAIRS OR ALTERATIONS Siad v Z
The undersigned agr s to je�teni
above described Individual Sewage' Disposal System in accordance with the provisionsofTITLE 5 and
further a ees t la ' eAqfio '' a Certificate of Com liatrc has been is ed b the Board of Health.
Signed Date P y
Inspections
No. � ° .. C_•°" 6 � -- � �.� � � S FEE
COMMONWEALTH Of
Board of Health, V '{ViO�, M4 , MA.
CERTIFICATE OF COMPLIANCE
-�
.Description of Work: ZWrTdividual Component(s) C3 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded+- ; Abandone
by: 1--�lI t 5, Parc �-' �� Cc:6}
at. 69rid
has been installed inccordance with the rovisions of 3].0 CMR 15.00 (Tide 5) and the approved design plans/as-built plans relating to
application No. dated v ;Z . Approved Design Flow
> (gpd)
Installer cc,j}
Designer: Bd l:^h4/ Yi Inspector: Date:
The issuance of this permit shall not be .construed as a guarantee that the system will function as designed.
No.3 V,- +i ""� f K -. FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health,i(L{iC3i�Tei� , MA.
DISPOSAL. SYSTEM CONSTRUCTION- PERMIT
Permission is hereby granted to;,, Construct( ) Repair( ) Upgrade ��bandon ( ) an individual sewage disposal system
at 1t i x.,06 �' � `��� Li';`t (1j); --,V7 'mA as described in the application for
Disposal System Construction Permit No. - dated
Provided: Construction shall be completed within 4zk s o� the date of this permit. All local conditions must be met.
Form ]255 Rev. 5x96 A.M. Sulkin Co. Chadeslown, MA Date lb BOard Of Health