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14 COMMONWEA11H OF MASSACHUSETTS
t� 1 Board of Health, YCK7 ; -t 0 , Z } 1yq q
APPLICATION FOR DISPOSAL -SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( Repair(} UpgracWC Abandon( } ; 4tomplete System O Individual Components
Location F % t ¢j� t• Owner's Name1
-�L
Map/Parcel#
Address �.
Lot# - Telephone# _ f
' Installer's Name rk('1A 1 c..,QV�� Designer's Name
Z C 1
�-f Addre' -
Address �Q �c) ss
�bLJ C _; 1 . it
Telephone# i _ - Z �j }� �, ' { Telephone#
Type of Building ? �1 � O [ G ` IAL Size _ I � �C�` sq. ft.
Dwelling - No. of Bedrooms Garbage grinder Q4
Other - Type of Building 1 No. of persons Showers F ), Cafeteria (i Y
Other Fixtures _.. i r: t � C� � � ..--.. }'� . -� S > � , _�
Design Flow (min. required) K` gpd Calculated dew flow f� Design flow provided �•r{ 1 _r _'(.pd
Plan: Date r, : xl Number of sheets _ }! Revision Date
Title r•'
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator ��e� ��, Date of Evaluation
T
DESCRIPTION OF REPAIRS OR ALTERATIONS_ � Pt� �'. a` , V\ 1n \
i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agreed to not to place- the systyto in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date _ `
Inspections
No. �_`-t 1 �� _ FEE
COMMONWEALT14 OF MASSACHUSETTS
Board of Health,`t'`.1 x� ,�` MA, As (l
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) :'Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded, Abandoned { )
by: t ->tii/
at - -� ( r-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
application No. ,% ! "1 , , dated r v j, ; �. Approved Design Flow (gpd)
Installer r (�, --<•
Designer; Inspector: ( >_ , � Date: '
-r Y l i
The issuance of this permit shall not be p6nstrued as a guarantee that the system will function as designed.
c.--------------__.
No. r -, Z�C" • LO`� FEE . 1:
COMMONWEAM OF MASSACHUSETTS
Board of Health, . -)t , M,q,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade / Abandon ( ) an indhidual sewage disposal system
C
at T �.. flUc2_- C �C,(1Q .� as described in the application for
Disposal System Construction Permit No. 1 dated "1 `/ .�c•--L-
Provided: Construction shall be completed within three-year& of the date of this permit. All local conditions must be met.
Form 1255 Rev.5M A.M SulkinCo. aakoAi MA Date 1 .l a tI Board of Health
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