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No. �� �� (PZ
pt FEE—
!�a COMMONWEALTH OF MASSACIIUSETTS
Board of Health, Wt OA
MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair{X Upgrade( ) Abandon( U Complete System ❑ Individual Components
Location 7zl�- /,/4e401- V c
Map/Parcel#
Lot#
Installer's Name
Address
Telephone# -7-7
44 MLM16Wtj Owner's Name
Address / jjUD e tuj C-r j
Telephone#
�o Designer's Name N 4
Address
Telephone#
-hA Ile--c', FL 3
Type of Building _ _ 'l' ✓ , _ Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided d
gP
Plan: Date N
'u
/mber of sheets Revision Date
Title —� `7 HLi/fit i� llye 4 rLl110S.16-4411l
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR AI TERATIONS C44 e i f lLi GC r 7 -j
•The undersigned
gn agmep to instill a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place th system in operation until a Certificate of mplijince has been issued by the Board of Health.
` Signed Date
Inspections
i
-244 (6 COMMONWFALTII OF MASSACLIUSETIFEE
'S
Board of Health, jyJpL'AIA ---'�
`/ CERTIFICATE OF COMPLIANCE
Description of Work: �® lndividual Component(s) 0 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired A,), Upgraded ( ), Abandoned ( )
by:
at jAleq
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,N9. r;1� dated d` Approved Design Flow_ _(gpd)
Installer
Designer: Inspector: t ,wl( Dater
The issuance of this permit shall not be construed as a guaran ee that the system will function as designed.
FEE
COMMONWEALTH QF MASSACHUSETTS
Board of Health, _ 7'dL��i MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(�f Upgrade( ) Abandon( ) an individual sewage disposal system
at 'J< I �laj�.� Q� �Gi1 `�/�f�6��
as described in the application for
Disposal System Construction Permit No._241 I ?J dated
Provided: Construction shall be completed within /"e vent of the date of this permit. All local conditions must be met.
Form 1255 Rev.5/96 AM Sulkin Co COMA Date 5 . t 1 Board of Health
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