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FEE.661
COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
AP PLICATION FOIA DISPOSAL SYSTEM CONSTRUCTION PERMIT
' plication for a Permit to .Construct( ) Repair( ) Upgrade( ) Abandon( ) , omplete•System ❑ individual Components
Location
Owner's Name
Map/Parcel# el
Address
Lot#
Telephone# 7.7G - C
Installer's Name Kms, IJ
Designer's Name �pp l f
Address , 11
U 4 f Ar nvi � ��T
Address
or I S ti( 17tt+ � A
Telephone# 779- 9 3G ' G q6,)
Telephone# _ (� L - L7
Type of Building' ?,Si'G�tn �`a 1 Lot Size_ sq. ft
Dwelling- No. of Bedrooms f e Re jv(jc.-4, Garbage grinder
Other - Type of Building No. of persons Showers (' ), Cafeteria
Other Fixtures
Design Flow (min. required) �3 V gpd Calculated design flow Designflow provided gpd
Plan Date �/ ' a� `` .261!1 Nuinber of sheets _) Revision Date.
Title
Description of Soil(s)' * ! �D�S yp " In " p4rrl fti►�
r
Soil Evaluator Form No. Name of Soil "Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
4- , 7.,3 4 l l I Srw
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 Compliance has been issued by the Board of Health.
Signed Date - o N
Inspections
No. 60 ViLy-im' P.� f�e FEE
COMMONWEALTH .TH 'Ulf MASSACHUSETTS, e
Board of Health, Af7M1jn+ , MA. 0 -r�
CERTIFICATE OF COMPLIANCE � `C
Descriptiori.of Work: El Individual Component(s) Jh^mplete System o,I
a
The undersi�gned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), upgraded (}, Abandoned
r
at.—
has
t_has been installed in accoi�nce with the provisi ns of 310 CMR 15.00 (Title 5) and thea proved design plans/as-built plans relating to
application No. �- l i dated Approved DesignFlow (gpd)
Installer
Designer: is 6r s S X0 _ u o +w,H Inspector: Date:
Trhe issuance of this permit shall not be const', ued as e that the system will function as designed.
J"N FEE
.COMMONWEALTH Of MASSACHUSETTS ��� T ,D1.0
Board of Health, 1�1� M
�A:
DISPOSAL, SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal systeri
at _ e, pvk as described -in the application for
4F'.; 7` J� oAt.
Disposal System Constt uctron Permit No / ,dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin. Co; Chadestown,MA Date Board of Healthl '