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COMMONWEALTH OF MASSAC14USETTS
Board of Health, �'' ENL I e-1 " MA.
APRICATI®N fOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) - ❑ Complete System IdIndividual Components
Location (�`J •• �� S
Owner's Name -!�cG.0 bo Cw
Map/Parcel# 177 2
Address Q. caA- 1'1<s"IJA )`J SULAAn G!t-
Lot#
Telephone#
Installer's Name JLa�
s Designer's Name
Address {, l 2 o a% k CZ i
Address MC,
Telephone# 7 S l
Telephone# c1 --
Type of Building Lot Size
Dwelling - No. of Bedrooms X r�7 A0 k
Other - Type of Building O-P v. [< r ? ' t l t l
YP g , — No. of persons
Other Fixtures
sq. ft.
Garbage grinder
Showers ( ), Cafeteria ( )
Design Flow (min. required) 3 2 V gpd Calculated design flow er Design flow pro%ided gpd
Planate S— U ]. Number of sheets Revision Date
(` Title 1
.,, Descriptipn dfSoil (s) N1 ci\V--
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS 1 .1 <, �, i V.'-11 L V ti O)C - 3 %d ;2 0
I _ C F i u v ; S cr _ , K�. � ; ��r � or S C rCxl-.j
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of T= 5 and
further agrees to not to plac the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed �► -- Date C
Inspections _
No. k (-y t-1
Board of Health, _ \ ' _ _ _,MA.
CERTIFICATE OF COMPLIANCE
01� v. l
I LI ) w)411 FEE
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Description of Work: eindi�zdual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V, Upgraded ( ), Abandoned ( }
by: SCOT
has been insitlled in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. Q;/- ! (% dated _ /U J Li' I Approved Design Flow ) J (gpd)
Installer S CO
Designer: — GA Inspector: �;-h(tDate: IU'
The issuance of this permit shall not be construed as a guarantee that the system will fut*tion as designed.
No. t 2LA -2 FEE �7Z
COMMONWLAI.T-I OF MASSACHUSITTS
Board of Health, \ fl g , \-\� � Lt , AM.
DISPOSAL SYSTDi CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(V Upgrade( ) Abandon( ) an individual sewage disposal system
at e-r C13- 0Uty, yC-fMJ as described in the application for
Disposal System Construction Permit No %/ Z8 Q dated Ln_/
L
Provided: Construction shall be completed within lrene_Ite�r� of the date of- All local conditions must be met.
Form 1255 Rev 5/96 A.M. Su kin Co. CharWwm, MA Date/ 0 - / ,-) It Board of Health -
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