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COMMONWEALTH OF MASSACHUSETTS
�f Board oJHealth, t;';.�MF� f ►� , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair(, Upgrade( ) Abandon( ) - O Complete System Q (Individual Components
Location �� oL�
Owner's Name a I-i Z 6
Map/Parcel# 5 axs
r 7 j3q
Address C.iv -N7S Y��y�pv
Lot#
Telephone# 0
Installer's Name abjxT1 qLAr j� _�c
Designer's Name
t
Address 3�D W%��-C S aY !�'� v�+
Address
Telephone# 5pJ3- S0q, yo5-8
Telephone#
Type of Building
Dwelling - No, of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Lot Size
No. of persons
sq. ft.
Garbage grinder( )
Showers( ), Cafeteria ( )
gpd Calculated design flow Design flow provided
Number of sheets _ Revision Date
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS k�,1 L;kze D _N 1 �' �vX t� ► w° l 5�.1"
gpd
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees toj,ttlace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed hn � I -Ai 3. L t.I(0• .ir r, C • Date G 5 - 4: j
Inspections
No ` Z44 COMMONWEALTR OF MASSACHUSETTS I d,
41
Board of Health, Yh p V % MA.
CERTIFICATE OF COMPLIANCE
Description of Work: 01ndividual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repair etl�fQ. Upgraded ( ),Abandonedby: ( )
r
62. k r7G . r
at 6 ;
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
application No. � Xk - � i `-k , dated � --I�j` + Approved Design Flow _._ (gpd)
Installer k�� R,DVr
Designer: tj A Inspector: _ Date, �i Jai
The issuance of this permit shall not be construed as a tegth�f the system will function as designed.
No. iQ20A—)K- -2-4f 1 __4-,
FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, 9CMMA11 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(
at5_K�,^Kee- J)t'
r
Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. lam, dated
l
Provided: Construction shall be completed within thcae w-axs.of the date of this t. All local conditions must be met.
Form 1255 Rev 5/% A-M SulkknCo. CtIB t Own,MA Date t ' Board of Health
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