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No.
z„ q2, bC.07--LLf-(o5
COMMONWEALTH OF MASSACHUSETTS
Board of Health, U-re1 , ..
FEE.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade Abandon O O Complete System Individual Components
Location 44 kall AusdaTT Owner's Name n P,
Map/Parcel# Address j7,0, �Z
Lot# Z Telephone#
Installer's Name Designer's Name Z
Address t S Address Z�S4 C `
Tele hone# 1
P r 7 Telephone# �it4 -77'� /��
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building —
`,1 Lot Size _ 10-713 4 sq. ft.
tL� Garbage grinder ( )
No. of persons Showers O Cafeteria ( )
Other Fixtures �^
Design Flow (min. required) 4qo gpd Calculated design flow Design flow pro, ided Q gpd
Plan: Date ��- dZ _ Number of sheets __ __�_ Revision Date
Title �. R4
Description ofSoil (s) 154"D (U-24.rr /$ , PC*A/
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
_ 1 v u -
CON� t
The undersigned`agrees to ins�4
further agrees to tot to placg1
Signed
L
Inspections
No. !L ( 2 i 2-
Name of Soil Evaluator
Use exisTt
Lc G N-
L Date of Evaluation 3 - 2_O,Z4
- 04eGI,
above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
em in operation until a Certificate of Compliance has been issued by the Board of Health,
Date q- u - Z g7�1
COMMONWLALT14 OF MASSACITUSETTS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) O Complete System
The
by:
at
FEE_
tied hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( , Abandoned( }
.210
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. dated / d`I Approved Design Flow �1�{�(gpd)
Installer Rownrr a. /It ry (- U
Designer'IC EUkiA )ta!XJJLY ri" Inspector: 1,r ,1 Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 1 Ce 2-
COMMONWEALTH OF MASSACHUSETTS
Board of Health, —Y&Zft D V Tl.*- . MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE
Permission is hereby granted to; Construct( ) Repair( } Upgrade (� Abandon( ) an indi�zdual sewage disposal system
at 'I}�F' v srr as described in the application for
Disposal System Construction Permit NoJ-Z_, dated <
Provided: Construction shall be completed within ���' f
p ���teacavf fie date of this emit. All local conditions must be met.
k:c 1255 Rev 5/% A.M. S: kin Co Dw6goon, MA Date ./ '-.i � 1_ Board of Health �
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