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COMMONWEALTH Of MASSACHUSETTS
Board of HeaUlt, Mil.'
APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT �
Application for a Permit to Construct( ) Repair( ) Upgrade(t/ Abandon ( ) - ❑ Complete System 4ndividualComponents
Location
Owner's Name
Map/Parcel# ¢j
Address
Lot# i 7 6
Telephone#
Installer's Name t O t Lb0(51-�(.,,.j t 3 11\r"
Designer's Name , 0 t
Address Z
0� -(^ �} PJ Z-(— a 7fcq
Address -) l to C
Telephone# �E3._ °Z.--C-(I
Telephone#
Type of Building Lot Size 1 � �l 62 sq. ft.
Dwelling -No.of Bedrooms 3 Garbage grinder( )
Other -Type ofBuilding �__�saM•..t1A No. of persons Showers( ),Cafeteria( )
Otter Fixtures
Design Flow (min ,Jrequii d) C l (Z_ gpd Calculated design flow 330 Design flow provided 33 1, G;l gpd
Plan; Date r 1 % 1 1 Number of sheets i Revision Date
Title
Description of Soil (s) —
Soil Evaluator Form No.
Name of Soil Evaluator
of Evaluation
,
DESCRIPTION OF REPAIRS OR ALTERATIONS )
,h• • ....�.. 1. .w. A • .y- n n .. _
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 tplace tem in operation until a Certificate of o i l'aace has been issued by the Board of Health.
Signed—fdf/JI- (i /4Mi' Date Z; 1
lS
C
No. 1 �)['...(,. ... - ui I r//e - CLL
�f rid COMMONWEALTH OF MASSACHUSETTS
Board of Health, Fjr�12,A4 (.Y1_7i NIA.
CPRTIPICTP OF COMPINC
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Description of Work: Edividual Component(s) ❑ Complete System - s`..c�� �,,r,�G'�% ( �j,,�`Ljt✓,_r''
The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (l,.)�Upgmiled O,Abandoned O i
it
has been installed in accordance with the provisions of °10 CMR 15.00 (Title 5) and ti�ne ap roved design plans/as-built plans relating to
application No. /�- ;i � dated f'F_ .1� � f 4. Approved Design Flow gpd)
Installer _ M t CA-iA tc'1_ n' '- t_. C �Y:�L.l_K� 11 . ,, i
Designer: ' f .1. VInspector: Fel 1' s r" dw ry '' Date:
The issuance of this perm&)shag not be construed as a guridatee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Al tin+ ; MA.
DISPOSAL SYSTEM, CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(v) Abandon( ) an individual sewage disposal system
at m_ a&6 V V sat t i, 1:4tWrO. 1i0t?Y as described in the application for
f
Disposal System Construction Permit No. / Y ' i- , dated
Provided: Construction shall be completed within thr�of the date of this permit, All local conditions must be met.
Fan 1255 aw. 5M A.M. Sualn GD. Gatedoattih Date� �`,%� Board of Health