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No.� S�r/ !i( /(! 0 FEE
Board of Health, 11.46 ACIUr �_ f2 12) , MA.
APP ICAJ�®]� R DISP �� JCTI®N PERMIT
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Application for aper t to Construct( ) Repair( p ra ()Abandon(.) - ❑Complete System L1 Individual Components
Location 6 __e,51f
Owner's Name C cj rci
Map/Parc G / ���
Address
Lot#
Telephone#
Installer's Name
Designer's Name p yV�u i3, cs a�
Address42Address
139
Telephone# 3
Telephone# SC4— 3 3—d-1-7
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms / Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) 5 3V gpd Calculated design flow _ Design flow provided gpd
Plan: Date acl G Number of sheets Revision Date
Title
Description of Soil(s) (�� �' sci Lem('
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS
Date of Evaluation
—The undersigned ees to install the above described•Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr t of lac a operation until aCertificate /of�ompliance has been issued by the Board of Health.
F Signed!/ Date Y '
irf.,�pections
No. !/ —� ) FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, / c ✓ , c , 7 d:. -) MA.w::. ��� 6�
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) (�Pcomplete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by: 1_1I I S 6(_c1-)'I;S is,' -. Cc
at �We ��I �5S5A 1- S%G P7 Sc&i %l 1 �Z, c ,/1 S;�isem.-,
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has been installed in.accordarKe with the provisions of 310 CMR 15.00 (Title 5) and th� j�proved design plans/as-built plans relating to
application No. �� �� dated ' S ov Approved Design Flow -� (gpd)
Installer I_ / l i 6<c / -0 i J r" c
Designer: !y ,� , i/1� / j h ti S G1 Inspector: Date: b 6��✓
The issuance of this Permit shall not be construed as a guarantee that the system will function as designed.
No. `/sV &Z.. L ( FEE 7 , 1
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
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Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
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at ` r 0 5 S 5 J )- 44, /' -7 j--; ? as described in the application for
Disposal System Construction Permit No. dated Q
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Provided: Construction shall.be completed within t; of the date of this permit. All local conditions, must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date'J V 6)3 Board of Health C�
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