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COMMONWEALT14 OF MASSAC14USETTS
Board of Health, N _ , MA.
APPLICATION LOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct(. Repair( ) Upgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location�AcnwA n '-ft AY)
Owner's Name
Mapr'Parcel# _-
Address -\ �Ntff4U1
Lot# J
Telephone#
Installer's Name J �,�� �ub ��
Address �r �{ , A.IACX03
esigner's Name , \
Address
Telephone# r
Telephone# i �a W
Type of Building L&`�1fkw,1\0—,\ Lot Size 3����`'l sq.ft.
Dwelling - No. of Bedrooms ,] _. Garbage grinder (0c
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow (066_ Design flow prodded �P ,0(i gpd
Plan: Date Number of sheets Revision Date
Title
Description Qf Soil (s) _
SM Evaluator Form No.
Name of Soil Evaluator 14I ate of Evaluation ,1111 cm
r._
W-C`� U , --3
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
Inspections
- it t�1 Lt ►1�i .�- Ax
_ _ _
(�40NWLALTII OI; 'iNIASSACI4USETTS
Board of Health, MA.
CERTII~ICAT Of COMPLIANCE
Description of Work: Q Individual Component(s) Xcomplete System ((
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired
by:
at
FEE1��
r_�
9J, Abandoned( )
has been installed in accordance with the p'-ov� ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. �� -G'I3 , dated y' � 2c--7Z Approved Design Flow L (gpd)
Installer Ac
Designer: - -_ Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system win hm lion as designed.
No. FEE k\ 1.:
COMMONWEALTH Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; ConstructM Repair( ) Upgrade( ) Abandon( ) an indiN idual sewage disposal system
at as described in the application for
Disposal System Construction Permit No?? -C-"7? , dated
Provided: Construction shall be completed within Areeveau of the date of this permit. All local conditions must be met.
Form 1255 Rev 5196 AM $ulkin Co. ChakSlowRMA Date Board of Health _�, ___._ ___� • __
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