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No. _�I3 � 1 � �--- l.4 FEE 7 J V CJ
COMMONWEALTH Of MASSAC14USETTS
/ tet Board of Health, k� d ) , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Zp lication for a Permit to Construct( ) Repair( ) Upgrade(`�Abandon() - ❑ Complete System VIndividual Components
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Owner's Name
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p/Parcel# 60 'aAddress
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Telephone#
Installer's Name �' LZ-�
Designer's Name
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Address)hone#
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Telephone#
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Type of Building -- � j J y V' L 2 T D'Jyv))LA 11 Lot Size J 7 � C3 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re 'red ' J gpd Calculated design flow�� b Design flow provided gpd
Plan: Date �' 0 _ + Nu�ibber ao�f s�hee j - Revision Date V
Title
Description C il(s nR 1+� ` '� �(�' �b' /z� " p,, -
`� 7ERY, C� 7 3L -P !�
Soil Evaluat FA r�mTo�L Name of Soil E aluator v uation
DESCRIPTI �oF� C'�STE�,���� TERAT NS J C La. � L L )
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The undersijmed agrees to ins a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre to not to place tem in operation until a Certificate of Qbmpll ce has been issued by the Board of Health.
Signed Date q 2-S 1.3
Inspections (o
FEE
COMMONWEA1114 OF MASSACHUSETTS Ito
Board of Health, MA.
CERTIFICATE' Of COMPLIANCE
Description of Work: 4dividual Component(s) ❑ Complete System f -OK
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�0The undersi d p
)neherey ertify that th Sewa a Dis osal S stem; Constructed RepairedOUpgraded Abandoned
by:
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at
has been installed in accordance �wigrth the provisions of 310 CMR 00 ( ide 5) and tlLe roved design plans/as-built plans relating to
application No.'/ Q �dat /%/) -1 j�Ap`(rovt Ign Flow (g d)
Installer
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as`designed.
No. 0 Y FEE /} Ir dry
COMMONWLAIT14 Of MASSACHUSETTS /Z
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT'
Permission is hereby granted to; Construct ) Repair( ) Upgrade l l Abandon( ) an individual sewage disposal system
at as described in the application for
�M Disposal System Construction Permit No. C' dated
G W51
.
Provided: Construction shall be completed within-th-r�6f the date of this permit. All local condition � ust be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date r % Board of Health
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