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COMMONWEALTH OF MASSACHUSETTS
Board of Health, MA.
APPLICATION FOR DISPOSAL YSTI~M CONSTRUCTION PERMIT
Application for a Permit to Construct( ; Repai Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location koW0 &1� �
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Owner's Name
Map/Parcel# 38
Address ka '
, 4QUt1¢I --- U )- ,41 ,
Lot#
Telephone#
Installer's Name ����j%
Designer's Name
Address ,QC W oql-
Address gUD
J::AWOVT,4 jetj O/y4S�-iP�l� 4W- J
Telephone# ,f �8 54 7-- -; ? 7L7/
Telephone#
-7 7 — Y1717 — 70 72 11
I
Type of Building GNod 15,
Lot SizeL1, Zoo 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 z� Design flow provided l gpd
-Plan: Date 202 z Number of sheets A- Revision Date
`" Title V Sc_
A D�escriptionofSoil(s) �^------_------- _ _
_• �� -&,il Eva'uator Form No. Name of Soil Exalitatorz4z; u HE 110; ate of Evaluation
DESCRIPTION OF REPAIRS OR74.TERATIONS /i116-41 "76 do �46__ __ A/t✓/� /i/�LC% f' '� /x X
y. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and ' o era 'o un ' a Certificate of Comps
further agrees to o place tem liance has been issued by the Board of Health.
Signed Date . Z _
Inspections
No. 60 b�Z-:27-2-1 ?&
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FEE
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Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ), Repaired (>(, Upgraded ( ), Abandoned
COMMONWEALTH OF MASSACLIUSI
Board of Health, , �TA , , VL4
CERTIFICATE Of COMPLIANCE
at �� ✓�%/z�?!J �/� y �/ (/� •����/ ! �/✓/lam!/ f ! �, r/ /� QL� / �? f- -
has been installed in accordance with the provisions of 3110 CMR 15.00 (Title 51- e appr design plans as -built plans relating to
application No., ' 1 dated _ 77 U Appro�,ed DesigniFlow (gp
Installer ,a ,�— -
Designer: _ Inspector:'I14 E4W Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. L.fl!/1% FEE
—
COMMONWEAITH Of MASSA IUSETTS
Board of Health, MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(k) Upgrade( ) Abandon( ) an indi-6dual sewage disposal system
at .fly 'iRII iv,44-' 14X94Vr,4-1. *W , as desctbed in the application for
Disposal System Construction Permit NoOV JJ dated 710K. '� 3
Provided: Construction shall be completed -within Three years of the date of this permit. All local conditions must be met.
Forth 1255 Rev. 5/% AM Wkin Co. Charkst ", MA Date 7� �� _ Board of Health
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