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COMMONWEALTH OF MASSACI4USETTS
" 7
Board of Health, _ , MA
U� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
'CApp1,1 cation or a/ eP rmit t Construct( ) Repair( ) Upgrade;,*'_`Abandon() - fd Complete System O Individual Components
Location _j',7'j,�7jp�t. G_ e
Map/Parcel# �GS-
Lot#
InstaIler's Name
Address,__
Telephone# 5_e1 1;Z Ire_
Type of Building
Dwelling - No. of Bedrooms
Other -Type of Building _
Owner's Name �Xe G/_f l�C1��jl
Address , J7W7, Oh
Telephone#
Designer's Name G f
Address
Telephone#
Lot Size sq. ft.
Garbage grinder( )
_ Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow 4min. requiretd) gpd Calculated design flow Design flow provided �S Z gpd
Plan: Dade is ,t ,r -\Ntber afsheets Rexision Date
Title
Description of Soil (s)
No. of persons
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
l/�� it 4. i _1 c✓ . 7Ti s7e,^ _
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed ` Date 1Gf3 0
' /o/ f 7
Inspections �t J�"J
.4
COMMONWEALTH OF MASSACHUS . T
Board of Health, Ga7i i- NM.
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( }, Repaired ( ), Upgraded (.,},'Abandoned ( )
by: 4..
at
has been installed in accor�daance with the pro-,7sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. .mod dated /d `Approved Design Flow d)
Installer
Designer: G/r_r iyG�.T Inspector: t-( Ll C — Date: �;% 7
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
FEE
C®MM®NWE LT11®F MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct(o Repair( ) Upgrade( ) Abandon( ) an inditiridual sewage disposal system
at 2 S -<- -JG -c }} as described in the application for
Disposal System Construction Permit No. 2iL�, dated
Provided: Construction shall be completed within d4 s of t >e date of this Kermit. All local conditions must be met.
�' "`� / Board of Health
Form 1255 Rev 5/96 A.M. Sulkin Co Boston, MA Date �; f , —
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