App-Permit-ComplianceNo. ,�C�'{-�j X31/✓J�1—/y—CSU' EE
COMMONWEALTH Of YIASSAC14USETTS
, 45;F14Board of Health, ���,-�1��� , �• j%� e � `7 ����
APPLICATION FOR DISPOSAL SYSTWICONSTRUCTION PERMIT.
'Ap:)Iicatioli for a Permit to Construct ORe air(.) Upgrad Abandon ❑ Complete System dvidual Components
a
Location -81 "►`$r%'
Owner's Name e 4 /dt / L(' .
ap/Parcel# 13 3 a
Address { l v �/r �J p�y�-� 1- `l{ /fl t -e
ot#
Telephone#So ►3C� —f ,S
Installer's Name (` 11 i 1W74?S
Designer's Name
Address a,3 r r !`0't
Address
Telephone# $ (�
Telephone# Sp J 3%
Type of Building✓%L-'
Dwelling- No. of Bedrooms
Other- Type of Building _
Lot Size ,9= sq. ft.
Garbage grindeW27
Showers ( ),'Cafeteria
Other Fixtures
Design Flow (min, required) �� gpd Calculated design flow Design flow provideo!:5-7/ gpd
Plan: Date Zs ,% , &4 "S Number of sheets Revision Date
Title
Desci
Soil I
DES(
The undersigneZ.Ve, to ' tall the above described Individual Sewage Disposal System in accordance with the.provisions of TITLE 5 and
further agrees tpi thee site o a' til a Certificate of Compliance has been issued by the Board of Health.
Signed C/ Date
Inspections,5/ if 4-+" jO'�
No. COMMONWEALTH OF MASSACHUSETT���
Board of Health, YA. Z) �3 ct MA.
CERTIFICATE Of COMPLIANCE
Description of Work: ITIndividual Components) ❑ Complete System M/1 )(
The undersigned hereby certify that the Sewage Disposal System Constructed( ), Repaired ( ), UpgradedR, Abandoned
by: PIfCiTnt;.S CG;J'�
of VTC-d �f}}i s+ G�%�):141
has been installed in ccord ce with the p1ovisio4i, 44io' CMR 15.00 (Tit'le 5) and the approved design plans/as-built plans relating to
application No. ., dated Approved'Design Flow-_(gpd)
_
Installer I " ! ! > :� rI c r _ �Z7 i
Designer: 913 y; 11J, 1 : t " /)S d c ,: , l -f S Inspector:. /f .oiJ 'r'� r Date:
The issuance of this permit shall not be construed as a guaran a that the system will function as designed.
,
No
COMMONWEALTH Of MASSACIPUSETTS
Board of Health, MA.
FEE
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade` Abandon( ) an individualisewage disposal system
at :�,t f !✓ C) ' C' s ' `� �' , s r t r 1 �a`► as described in. the application for
Disposal System Construction Permit No., dated'" Y
Provided: Construction shall be completed withiniO ars of the date of this p m f. All local conditions must be met.
Form 1255 Rev. 5/96 .M. Sulkin Co. Chad slown, Date /Board of Health % f t� .,- �' J 'L"'