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COMMONWEALTH OF MASSACHUSETTS
Board of Health,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT 1
Application for a Permit to Construct( ) Repair( ) Upgradef,4 Abandon(} - O Complete System 4hu ividual Cos"is
Owner's Name
Map/Parcel# /-2 3 OG
Addressry� G�� G+,,
Lot#
Telephone#
Installer's Name /
Designer's
Address/ �, G ��
Address pX /-QL.,iC/r4
Telephone# 2 pe-- ,f�
i
Telephone!
Type of Building
Dwelling - No. of Bedrooms j
Other -Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided 3—�— gpd
Revision Date ~
Name of Soil Evahtator/. _ ^* mate of Evaluation,%%�
DESCRIPTION OF REPAIRS OR ALTERATIONS
6.- 6
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
w-�,Y-11-
Inspections
r — -
COMMONWEALTH OF MASSACHUSETTS FEE S
Board of Health,
CERTIFICATE OF COMPLIANCE
Description of Work: O Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( }, Upgraded O, Abandoned ( )
by:
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) andtheapproved design plans/as-built plans relating to
application No. dated pproved Design Flow `' (gpd)
Installer
Designer: Inspector: I Date: I
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. -L:1(2—L FEE fT.
COMMONWEALTH OF MASSAC14USETTS //// 1 P'1 -; �9/
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade ( ) Abandon ( ) an Indhidual sewage disposal system
at rj7 -e-^
as described in the application for
Disposal System Construction Permit No, , dated
Provided: Construction shall be completed within ftf the date of this permit. All local conditions must be met.
Form 1255 Rev S196 A.M. Sulkin Co. Char!estuvgtlA Dat Board of Health
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