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,IL/Z)ClU COMMONWEALTH OF Ml 4 S CHUSFTTS
Board of Health,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade'} Abandon( ) - ❑ Complete System ❑ Individual Components
Location r.
Owner's Name KM
Map/Parcel#
Lot# ,lj
Address jar'v" ' 7'
Telephone#
Installer's Name t N ST77k chid
Designer's Name
Address Z 1 �� /���
Address _—
Telephone#
Telephone#
Type of Building er -
Dwelling - No. of Bedrooms % tv3
Other -Type of Building
--_ _ Lot Size ?1 9 — sq. ft.+ ,
Garbage grinder VIVO
No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min./requ�md) 3 d —gpd Calculated design flow Design flow provided gpd
Plan: Date < < i / NumbLer gi sheets
Title
Description of Soils)_ -
Soil Evaluator Form No. Name of Soil Evaluator
DESCRIPTION ION OF
k4° k,, lQ�%iJ
Revision Data
1,f v �tfQ _
Date of Evaluation
Gov po
wig •i �., .s.r,� S
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to dot to place the system in 0172tion until a Certificate of pfi ce h/as been issued by the Board of Health.
Signed d_ f AVI Vr�/ram Date 7y Z `1
Inspections
No'7P -211 -�- COMMONWWM OF MASSACHUSETTSO/'r- FEE.
Board of Health, L MA. �UFRTIFICA F OF COMPLIANCEqk,
) L
Description of Work: O Individual Component(s) El Complete System 0 ,a
The undersigned hereby certify that the Sewage Disposal System; Constructed (), Repaired (-f:,-U, pgraded ( }, Abandoned ( )
at�rc0---
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.c�'/ UGf t) dated a',_ `! Approved Design Flow (gpd)
Installer I r 14 1.1 a L'c ,r / 1A 70 _ ---
Designer: Dc, J � %% n v` Inspector: —,, r - -i-'Y- Date: The issuance of this permit shall not be construed as a guarant�e that ties Stem will function as designed.
No. C- .24
FEE__
COMMONW LTI OF MA4 SACHUSETTS
Board of Health. IrAl t / MA.
DISPOSAL SYSTEA CONSTRUCTION PERMIT
to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No.r t'/1 &9 Q dated
Provided: Construction shall be completed within4hfoo-mask9f the date of this,pef3pm All local conditions must be met.
Form 1255 Rev 5M6 AM. Sown Co. Boston, MA Date " ( t Board of Health !�
Permission is hereby gran i
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