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CD111C,65 FEES" --
COMMONWEALTH OF MASSACHUSETTS
t Board of Health,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repairs+. Upgrade( ) Abandon( - O Complete System Cl Individual Components
Location
strol jo ,,
Owner's Name _ r q yt
jo't
Map;'Parcel#
� � ///'�
Address
Lot#
Telephone# 4 0 Ff Fr
9S6
Installer's Name
Designer's Name if J/
Address r
�9�
Address 1,40 &-A -3V
Aril G
Telephone S
Telephone# `] %
116
Type of Building _. 0&-, ] / A r
Dwelling - No. of Bedrooms
Other - Type of Building 5� 41
Other Fixtures
Design Flow (min. required) gpd Calculated design flow
Plan: Date Number of sheets
Title
9
Lot Size sq. ft.
Garbage grinderAJ
No. of persons Showers ( ), Cafeteria ( )
Design flow prodded 3'- gpd
Re-ision Date
Description ofSoil (s) •Se- z �-,�
Soil Evaluator Form No. Name of Soil Evaluat(; J �� Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned s to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t to p the on until a Certificate of Co¢rpliance has been issued by the Board of Health.
Signed r �� Date_
Inspections - —
No. ? _}.� >♦�"4 FEE
COMMONWEALTH OF MASSACITUSETTS 1 _
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) U Complete System
The undersigned hereby certify that the Sewage Disposal System-, Constructed ( ), Repaired (�Upgraded ( ), Abandoned ( )
by: !. !_T�jlgy %hPi A C0,25-f
has been installed in accordance with t rovisions of 31kMR 15.00 Title
P ( )and the approved design plansias-built plans relating to
application No. _ _ dated ;;.r Approved Design Flow (gpd)
Installer
Designer_ _ I c. Inspector: � / � P _ Date: tt,V% L
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. f
No. f t
FEE
COMMONV ILALT1I OV MASSACITUSETTS
Board of Health, o c AM.
C
► DISPOSAL SYST I CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( Y) Upgrade( ) Abandon( ) an individual sewage disposal system
at a 3nh .t �� t! - z (� ,�S'�• L ,-•^y oa 14 as described in the application for
kor
Disposal System Construction Permit No. ? 1 1, , dated / I ) t c t / "��
I.i
Provided: Construction shall be completed within tfue - ; of the date of this permit. All local conditions must be met.
Form 1255 Rev 5/% AW Sulkin Co. ChadesimftMA Date Board of Health `_�_
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