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No. Le � Le ��„� � 9� a�`1
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COMMONWEALTH OF MASSACHUSETTS
Board r f Health, llvtlll.11MA.
ff APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construe:( ) Repair( ) Upgrade ) Abandon( ) - O Complete System (Individual Components
Location /'
Map/Parcel#
Lot#
Installer's Name al, i, . l r 1 i
Address
Telephone# ., 51A- Lrrt_ '.
Type of 86ilding I'���Klri7'lJ1
Dwelling - No. of Bedrooms 3
Other -Type of Building
Other Fixtures
Design Flow (min. required) 312 2 _ gpd
Plan: Date G'" -21921// Number o
Title /�� i J�
Description of Soil(s)
Owner's Name/� 41 r 'F / �t
/
Address i�7 !�}r'i�fi;�lt((I L/'Qr<-
Telephone#
Designer's Name li ,
Address IZ ,^/t 6a,"A/"/
Telephone# -0' V'117- 5.?/ 3
Lot Size /2 x sq. ft.
Garbage grinder( )
No, of persons Showers( ), Cafeteria ( )
Calculated design flow 3 y; % Design flow provided gpd
heets Z Revision Date
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR AITERATIONS
4. I i 1)( -/ 6 ) // iU jS /,i� ��j //,rv,,
AA-- Date of Evaluation S - / G ZOO _�
The undersigned agrees "4d) the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not16 plare,ibe system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed _ Date
Inspections
No. .,�� y� , ���
COMMONWEALTH OF MASSACHUS.FTTS FEE
Board of Health, _ M41OG �I , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: WIndividual Component(s) O Complete System
The undersigned , ereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned ( )
by: ,
athas been installed in accordance with the provisions of 3I0 CMR 15.00 (Title 5) and the approved design plans/as-btiilt plans relating to
application N dated Approved Design Flow_(gpd)
Installer zf / u.
Designer: _ _Lw ,�� /i^� Inspector: l � i—Date:-.
/ t e
P_-- I . Date: __
The issuance of this permit ship! not be construed as a guarantee that the system will function as designed.
No.5�7� � �
COMMONVNTEALTII OF MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade(30 Abandon( ) an individual sewage disposal system
at o / W GlI.r L V/i/1)4�lwaA as described in the application for
Disposal System Construction Permit No dated - 9
Provided: Construction shall be completed within4+Fee-yeers.of the date oflhis`per it. All local conditions must be met.
Form 1255 Rev 51% AM. Sulkin Co Cha<Wum, MA Date ) P t Board of Health
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