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COMMONWEALTH OF MASSAC14USETTS
Board t f Health, ttii t� 4
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System U Individual Components
Location 8 �1 6/9 I A fmm-k r6ol
Map/Parcel# / L) 3 O 6 . /
Lot# r
Installer's Name
Address 3o IVAys1 an RJ -vs j�,, F
Telephone# 5-6 R _, 3 9 6 ^- o; 2 0&:�
Owner's Name J 1 m �-P-Ac ~ O r1
Address 167 -To Y1 f Q t R �) , P,, t3r b� 6
Telephone# 50e-a 7L{ - 6`s, j 1
Designer's Name QpWy`) C(YV
Address q3 q Mh r J ` , 'Ukrno v'�h Ir
Telephone# ,, Qg ��� _ .y�' L( i
Type of Building S -9- e- 3L D 6- 'CIAtN Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other -Type of Building 60),11ne\-G�GN- mom` �I No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min.)req -red) gpd Calculated design flow 3 Design flow provided a O gpd
Plan: Date _ Q J ti A 1 Number of sheets Revision Date
Title
DescriptionofSoil(s) IDQ-ieJ t71ev/e-y1
Soil Evaluator Form No. 1 ] 05 7 1 Name of Soil Evaluator C>-yv, r'eXt,art Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS �[r f -�r A,\ f-k - 0, C� 15 0 O k ► y\y, H -.1-), Li 0 -3
- v Soo Gp\to ck1�kn,6e-(-r (A,�, S vrt)kare., S on
i P\ sA GP,0�c
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further o not to plac ,e1�e s)jttem in operation until a Certificate of ompliance has been issued by the Board of Health.
Signed l /�.� r- Date
Inspections
�lL
No. FEE
COMMONWEALTH OF MASSACHUSETTSel _d&)t� �
Board of Health, � f � Z N'VI A � V'1 ,NIA.
lion of Work: 0 Individual Component(s) CI~RTIFIC�TE' OF COMPLIANCEDescri
p ponent(s) Complete System
The un ersigned hereby certify teat the�ewage Disposal System; Constructed ( ), Repaired K, Upgraded ( ), Abandoned ( )
by: In" --r - 1n r
It ' 1 - - 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.,- - i , dated- a Approved Design Flow 3 O O (gpd)
Installer IN) <-Y'0N,(:1 nT
Designer: 17oW h C Ap (= Inspector: , Date:__
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE. }
Permission is hereby gra ited to; Construct( V/Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at � � � � � � Cr
as described in the application for
Disposal System Construction Permit No �/ I �dated t /.
Provided: Construction shall be completed within rP of the date of thispeermit. All local conditions must be met.
Form 1255 Rev 5/% A.M. Sulkin Co. Chedae M MA Date 'l L ! / Board of Health
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