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FEE �-
` CONDIONWEALTI4 OF MASSAC14USETTS
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Board of Health,2. : , MA.
APPLICATION FOP DISPOISA SYSTPM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - 0 Complete System ❑ Individual Components
Location ]
Map/Parcel#�3-
Lot# LA
Installer's Name �� (dti lit { tali
Address
Telephone# -_',5D�S -7
Owner's Name
Address ((4CK,.f_rS A-g e S• wr Mau`�in
Telephone#
Designer's Name
Address \ , () nnk 3 k &<i,,otCV f\e,0a%44
Telephone#
Type of Building 1-t Oy -a-C -C jt .� tr�a h� - Lot Size b'aL GCCCS sq, ft.
Dwelling; - No. of Bedrooms �l,_(3 �,� al L,,,� �� �� k1n ' _ - Garbage grinder N o
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 6 gpd Calculated design flo,3 41G Q Design flow provided !gpd
Plan: Date -7 1 I _ _Number of sheets _ Revision Date
Title
Description ofSoil (s) 1! e-
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
rV
r,11v2^
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 ® /
-��
b Inspections
COMMONWEALTH OF MASSACHUSETTS Y Ala FEE�
Board of Health, Q. �. , , ALq, l; r
t
CERTIFICATE '�- F COMPLIANCE
Description of Work: ® individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constt•ucted ( ), Repaired Upgraded( ),Abandoned( }
by:
at
has been installed in accordance with the provisi ns of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. dated Approeed Design Flow (gpd)
Installer S M Zf r.A,�
Designer: 0uyt r Oc.4o _ Inspector:.19 � Date:The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE =�
COMMONIATALT14®f MASSACOUSETTS
Board of Health, __. , MA,
DISPOSAL SYSTEM (CONSTRUCTION PERMIT
Permission is herebygranted to; Construct( ) Repair(Y} Upgrade( ) Abandon ( ) an individual sewage disposal system
at soj�r c- r N. t> -r . as described in the application for
Disposal System Construction Permit No.�dated
Provided: Construction shall be completed wi in t ree years of the date of this permit. All local conditions must be tnet.
Form 1255 Rev. 5/96 AW StAkfn Ce. CharksfM MA Date /� % 1 Board of Health
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