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FEE
COMMONWEALT14 OF MASSAC14USETTS
�- C6 Board of Health, . 1' ryxnrt ►�., MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) RepairX Upgrade( ) Abandon( ) - O Complete System 4 Individual Components
Location)
t, 5 r
Owner's Name h jt S jQ C D► j
Map/Parcel#
Addres.%63 Doowaq e T D 1
Lot#
Telephone# $Go. 2®q _ 683Q
Installer's Name
-ert ova to. Try--
Designer's Name
Address 3 �3
Wh .5 10G + - r ��f yn.�0L1 k
Address
Telephone# S 0,? 30 T-' j
Telephone#
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
PIan: Date
Title
Description of Soils) _
Soil Evaluator Form No.
gpd Calculated design flow
Number of sheets
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder( )
No, of persons Showers ( ), Cafeteria ( )
Design flow pro-Oded _ gpd
Revision Date
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS V) '}'GLjti A () ,) - �i -�(� -�r>>( (,�r 1
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 3 `%O ` 2 y
Inspections
No. a;�i��, . FEE
OF MASSACHUSETTS
Board of Health, , MA. OV,
CERTIFICATE OF COMPLIANCE
Description of Work: A& Individual Component(s) Cl Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired �), Upgraded ( ). Abandoned ( )
by. pert $ . Aur 40=.L, Lilt
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the �a}roved design plans.ias built plans relating to
application No. t - dated - _ „� / Approved Design Flow ZJ,, (gpd)
Installer f 2, EiV 69, ,
Designer:Inspector: 1__:;> Date:
The issuance of this permit shall not be construed as a guarafif a that the system will function as designed.
No.
COMMONWEALTH OF MASSACHUSETTS
Board of Health, KCPAP , MA,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at
FEE
RepairO Upgrade( ) Abandon( ) an indhiclual sewage disposal system
Disposal System Construction Permit No. 4/ dated
as described in the application for
Provided: Construction shall be completed within three years of the date of this permit. All local conditions mast be met.
Form 1255 Rev. SM AN Suakin Co Chaft< wr, MA Date << �� h �� Board of Health �
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