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FEE �_
COMMONVIALT1I Of MASSAC14USETTS �0 �
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Board rf Heallh, L47 1-?"CC4 MA. �t I
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APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
\pplicanon for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components
Location /r% Soy 1 I %
is Name j2 q4tA ( C 1 V'V
Map/Parcel#
Address a th I• AJ,;yl AvP .3
Lot# ,�2
Telephone# 4 S
I
Installer's Name �� r` Cc
Designer's Name 04-
Addressa 3 �� r %�
Address JO G �:t 3 f.
Telephone#
Telephone# �J7
Type of Building/
1
Dwelling - No. of Bedrooms ok
Other - Tvpe of Building
- /, o. ofpersons
Other Fixtures _
i,A--x
Lot Size Z'�f 1::�" D sq. ft.
_. - Garbage grinder Al J
Showers ( ), Cafeteria ( )
.g Design Flow (min. required) ' _ - _ gpd Calculated design flow 3�� _ Design flow prodded 74,"d' grid
`Plan. Date 1 Number of sheets
1 a Title4,64 -L----
Description of Soil (s) PP
ip Soil Evaluator Form No. Name of Soil Evaluator
Re%ision Date -
of Evaluation - l5
DESCRIPTION OF REPAIRS OR AI TERATIONS —.
The undersigned afire install the aboveTL
_de 'bed Individual Sewage Disposal System in accordance with the provisions of TIME 5 and
further agrees to pla toya"�z�'"( ti until a Certificate of, Compliance has been issued by the Board of Health.
Signed Date `� L
Inspections
off
. 0C,
�� COMMONWEALTH OF MASSACHUSETTS FED
Board of Health, r >"1 00_ MA.Cej - -6,*,
k' '
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed (; , Repaired Upgraded ( ), Abandoned ( )
by: � l3ln i i.o r s CG n (4
has been installed in accordan a with the provisions of 310 CMR I (Tide 5) and-fhe approved design plans/as-built plans relating to
application No. jk Al dated-, ;,� _. Approved Design Flow L(gpd)
Installer 7rf,_--, y
�
DesigneiPt of h o r"��`,{ jCn t*�� �lnspector: d D. Date: fq 1t.• I 'I a o _
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.
FEE
COMMONWFALTII OF MASSACHUSETTS
I'
Board of Health, L (_,LJ—, MA,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(-) Upgrade( ) Abandon( ) an individual sewage disposal system
at `'� 1� � 1 ii 4 I M C N 1 � rn� as described in the application for
Disposal System Construction Pe//rmit No - dated cK Q -
Provided: Construction shall be completed within r n_„„aac-s of the date of thispex;nit. All local conditions must be met.
Farm 1255 Rev. 5/96 A.M. Sulkin Co. Charlestm MA Date �� Board of Health
IVEcFwED
OCT0
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