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Nul4�Z O FEE _i-
} da COMMONWLALTII OF MASSACHUSETTS
Board of Health, AAA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - D Complete System l] Individual Components
Location ,1 _ Owner's Name L U
Mapr''Parcel# 11l Address l�tI �.
Lot# Telephone#
Installer's Name (' r� r` �hm Designer's Name �u71S 7�
Address Address Y 9 i I—'r�l 1
Telephone# 7 t ! a Telephone# 1
Type of Building ( - _ _, __ Lot Size sq. ft.
DwellingNo. of Bedrooms !
I -- -- __-_ Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
Description of Soil (s) I_- _
$oil Evaluator Form No.
Name of Soil Evaluator
C .J 1' -
Design flow prodded 0' gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TTTLE 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
Inspections
r -
No7r6ac ' FEE
COMMONWEALTH OF MASSACHUSETTS -9.
\'
Board of Health, _� (Y)2,4tMA,
CERTIFICATE OF COMPLIANCE C ,
.t
Description of Work: O Individual Component(s) O Complete System
Theune.1prsined(( er certi that the Sewage Disposal System; Constructed M Repaired ( ), Upgraded ( ),Abandoned( )
by: C. C t' ' u u }q� g P Y _
at
has been installed ip accordance with the provisions of 310 CMR 15.00 (Title 5) an he approved design plans/as-built plans relating to
application NoI dated y ` Approved Desi" Flow �` (gpd)
Installer C 1A at C11 v 4 C"_
Designer: r �01 ' G' Inspector: _ 7,11 )" i r Date:f
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 1 1 `
1 FEE.�
COMMONWEALTH OF MASSAC14USETTS
Board of Health, 3
`► 2KNn -0�, rA- h , llA_;�'
DISPOSAL -SYSTEM CONSTRUCTION PERMIT
Permission is herebygrahlted to; Copstruct�Repair( ) Upgrade( ) Abandon( ) an indiNridual sewage disposal system
at 4 1
` as desMbed in the application for
Disposal System Construction Permit No. II- ' , dated b 6 d1l
v1, _
)Provided: Construction shall be completed within direeweM'Snf the date of t-jis-permit. All local conditions must be met.
Form 1255 Rev 5/% kM Sulkln Co Chaelegam, MA Date ; —Board of Health
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