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Z� COMMONWEALTH MASSACHUSETTS
ASSACHUSETTS
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Board tf lealth, iyF f , MA. AV`L/v7/!
AIT.ICATION I;OIT DISPOSAL'
SYSTEM, CONSTRUCTION PER
Application for a Permit to Construct( Repair(v�UpgradO eAbandon( ) - O Complete System 1J'Individu.
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Owner'sNametj�y/fy
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Address
Lotil
Telephone4P 3 0�_ ,36 �- `y-/ s•."'
Installer's Namc ,:J
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_ Designer's
Address S a
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Address /�`•s c F'=o.+�cr .�
Telephone#
Type of Building S1it /�-' % .r.,.e�� �� Lot Size 'z Woe'' sq. ft.
Dwelling -No.of Bedrooms Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) ;;2, gpd Calculated design flow Design flow provided 74,LZ gpd
Plan: Date Numberofshects_ Revision Date
Title A, r,w.,.✓,�
Description of Soil(s) d" c�/'G v—y `� ,(3 ,G as-ri Zo,�.P.-��
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OFREPAIR.SORAITLRATIONS G/s.y v ,r,, 's
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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 /, X;
Inspections
t c. COMMONWEALTH OF MASSACIIIISETTS
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Board o/'Flaaltly �T`tail'bf)1 TH-
> CEITTIFICATE OF COMPLIANCE
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Description of Work: O individual Component(s) ❑ Complete System
The undersigned hereby certify that thCeSewage Disposal System; Constructed ( ), Repaired (='); Upgraded ( ), Abandoned ( )
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at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated . Approved Design Flow '%�..v.-;v ^r;(gpd)
Installer q i -ti to
Designer: :P°)Cali"^ "'{•c'..4 (^)(s^"` i^+�4)4i 1t ,'�: Inspect& ,J 4 ,, t*"t, t, y,,....,, Date:
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The issuance of this permit shall not be construed as a guarantee dra_t t the system will function asdesigned.
No. 9,2ot C "".e° ""a ,� \;a ti:,`� 'fr.:'. r.. tTM.:t , y ,�,.. ?...�.-�r.. �'"� W w�`> . 1 f,[})t +�.. fit C. FEC �ro
COMMONWEALTH OF MASSACHUSETTS
Board of Health, r VhnIM:k MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon ( ) an individual sewage disposal system
at r"`''`- — as described in the application for
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit., All local cgnditions must be met.
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Form 1255 Rev. 5/96 A.M. Suikin Co. Ohaleslan,KA Date Board of Healtl{