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COMMONWEALTH OF MASSAC14USETTS
Borrrd of Health, , M'q,
APPLICATION FOP. DISP r L SYSTEM CONSTRUCTION PERMIko � i 5 �
Application for a Pei mit to Construct( ) Repair4}Upgrade( ) Abandon ( ) - ❑ Complete System ❑ Individual Components
Location 5 �� ner's Name DVAII
Map/Parcel#Address
Lot# Telephone# f
Iris tailer's Name + Designer's Name
Address 7�1i �� Address St 9 4� P + n �/l)/e
Tel ephone* SU �b� —GZ Telephone# S 7 _ J 7
Type of Building _- .._ 4 Z--S / / .4 .. — Lot Size sq. ft,
Dwelling - No. of Bedrooms 4 Garbage grinderZ )
Other - Type of Building of No. persons Showers p (),Cafeteria ( )
Other Fixtt:res LZ
Design Flow (min. required) gpd Calculated design flow Design flow pro%ided gpd
Plan Date -''dz-' 'id— y Number of sheets - Reion Date
Title G S� pj, �/jGt �5
Description of Soil (s) _-
Soil Evaluator Form No. Name of So' aivat Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agree o install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to o Ce e,pt7u� e��r on until a Certificate of Com has been issued by the Board of Health.
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Signed Date � `—
Inspections
ok
No. Y� Z COMMONWLALT14 OF tit SSACLIUS ITS A 9 FEE tom,
Board of Health, aq, ��f ► I
CFRTIFIC OF COMPLIANCE
Description of Work: L) Individual Component(s) O Complete System
The tinders ereby certify that the Sewage Disposal System; Constructed ( ), Repaired (%� Upgraded ( }, Abandoned ( )
at
has been installed in accordance with the prON. to of 310 C 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. '< < dated / Approved Design Flow (gpd)
Installer j
Designer: 1 A (20n) Inspector: Gh uld &LDate: Ate/7 b
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No �f�
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COMMONWEALTI-I OF MASSAC14USETTS
G j Board of Health, . J- , MA.
DISPOSAL SYST6f CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( -) Upgrade( ) Abandon( ) an indiuzdual sewage disposal system
at J 5� • .�.vhJ (,�'� as described in the application for
Disposal System Construction Permit No. 'Z- 46 dated < l 1
Provided: Construction shall be completed within / i.� of the date of this rmit. All local conditions must be met.
Form 1255 Rev 5/96 A.M Sulkin Co. Charlessn,MA Datet-/- .) t Board of Health
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