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No. fiDc-l�-2=FEE. °
7/ COMMON AI. Or�&HUSETTSCt REGEWEED
Board of Health, y+4P...WLrQf , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PEIT APR, u 3 2019
plication fora Permit to Construct Repair() Upgrade( Abandon - ❑m'CoTete S tem El Individu , DEPT
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Location
RM L. Ai Vt
Owner's Name Tl'
Map/Parcel#r�G
�ca77
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Address S',
LoW
Telephone#
Installer's Name
a K� L yt>�
Designer's Name i 1
Address Po
X %tri _.
Address aG e n
Telephone#
t�8 776 6
Telephone# G 9S �qG
Type of Building' /.� jar^ /74 Lot Size Q°4 sq. ft
Dwelling:- No. of Bedrooms `v ® Garbage grinder ( }
Other -Type of Building No. of persons Showers (' ), Cafeteria
'Other Fixtures
Design Flow (min. r quired) a gpd Calculated d Sign flow Design flow provided �' gpd
Pian:Date 6 Number of sheets Revision Date
Title
Description of Soil (s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS putb — '1/1 ramaa 1! ' !q,4 al ✓) V,% /J
The undersigned agrees to install the above described Individual. Sewage: Disposal System in accordance with the provisions of TITLE 5 and;.
further agrees t ,not to place.the system in operation until a Certificate of Co pli ce has been issued by the Board of Health.
Signed / Date
t
'-inspections.
No. Z� j ` �^'�j{ � ..G/%�/�FEE
CO IONR LT14 OF MASSACHUSETTS b 4- �\��
, J24 q ISS
Board of Health; Y!a-�/1�[atrr , MA. �►k
CERTIFICATE OF COMPLIANCE
Description of Work:
El Components) Complete System
The undersi ned herebYcertify that the Sewage Disposal System; Constrii'cted ( ),Repaired ( ),`Upgraded ),Abandoned ( ).
by:: i�i L �,
at f�w� `� ✓
has been installed in accordance with the rovisions of 310 CMR 15.00 (Title 5) and the ;approved; design plans/as-built plans relating to
application No. - 7 dated Approved Design Flow (gpd)
Installer_ kr�,,K,
Designer: SNtjk,*% Inspector: Date:
The issuance of this;permit;shall ndt be construed as a guarante` a that the system will function as designed.
7,i COMMONWEALTH OF MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM ONTIJ TION PERMIT
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]FEE 00
Lils(e7
Permission is herebygranted to Construct( ) Repair( ) Upgrade ) Abandon( ) an individual sewage disposal system
at . �� RPG k/A r"A /tl `Jt_ as described in the application for
Disposal System Construction Permit No. lei - 7 , dated
Provided: Construction shall be completed w thiw h e- rs�of the date of this p.er i All local*,nd*'s must be met.
farm 1255 Rev. 5196 A.M. Sulkln Co. Chadestown, MA Date
--- Board of Health
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