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No. 1 J T vE'
FETE.
3 COMMONWEALTH OF MASSACHUSETTS
Board of Health, 1 t. , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ; - O Complete System El Individual Components
Location $ �O ua ��t o 1 IZ n '.
Map/Parcel#
Lot# (p
Installer's Name
Address 20u1 L I�?,+._ '�-(i114010, P
Telephone# q-4-+ U (0 5 3
Owner's Name
Address
Telephone#
Designer's Name 7, w
Address --
Telephone# (o� • ) �; (-�
Type of Building A )tk n / _ _ _ Lot Size
Dwelling - No. of Bedrooms 3
Other - Type of Building No. of persons
Other Fixture§
sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Design Flow (min. required) gpd Calculated design flow Design flow provided ? gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) j
Soil Evaluator Form No. Name of Soil Evaluator /v id a%)eN Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERAT16S �114CJWU o f n D tJ A bo,e a lNr, �. h _ (2 ' `� � � c 11 t>n 1-'1
hex A, � 4
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees-t-o not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections _
No. L �� COMMONWE�4LTI OF M nE 5
�1SSACHUSETT� }
Board of Health, MA.-7 j C
CERTIFICATE OF COMPLIANCE
Description of Work: $(Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed f ). Repaired ( ), Upgraded ( ), Abandoned ( }
by:
at h I )w 1{n 4f� 1C!'/.r - — has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
apphcadon No. _ �__, dated _ _ Approved Design Flow (gpd)
Installer X t -jo-{
Designer: rA G. Inspector: rif Date: L�
The issuance of this permit shall not be construed as a guarantee that the system will fun 'on as designed.
No.
COMMONWWTH OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE_
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at
as described in the application for
Disposal System Construction Permit No. zL4-f ¢,3 dated +
r'
Provided: Construction shall be completed within 1hre,e4e-ws-0f the date- _a is pe�- All local conditions must be met.
is
Form 1255 Rev 5196 AN Sulkin Co CharlestoiMMA Date _ Board of Health `�
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