App-Permit-ComplianceNo. G 1.0 `"1pe
COMMONWEALTH OF MASSACHUSETTS
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Board
Board of Health,a;6 x'sz a�:;�€ r1'SFAAPPLICATION FOR DISP@94�-'�."S�Y-STM—,C'�ONS-1PUCTION PERMIT
Application for a Permit to Construct( ) Repair( Y'U"-pgrade( ) Abandon( ) - Complete System ❑ Individual Components
Location oQ of C I ar-K Road a Ctrrno u+h D rf
Owner's Name Do r r
Map/Parcel# A-Aop 113 ct rc 1 136
Address ',Z�Z- C1 rIG Rd
Lot#
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Telephone# 5 Q g- 3 (o Z- X 1 3-7
Installer's Name ejZ_T `_ 3+j;
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Designer's Name D Q rr,en M. M etrF• S
Address Lan k
Address Go)( 4 8 1 G• SG r -A w (LA-- 625 3 1
Telephone#
Telephone# 5 Q$ -3 6 z_ z9 22
Type of Building XP -5
Dwelling - No. of Bedrooms _
Other - Type of Building
No. of persons
Lot Size
sq. ft.
Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures Lq
Design Flow (min. required) 1-� T l� gpd Calculated design flow Design flow provided 7�S /. !/ gpd
Plan: Dateg l a Number of sheets Revision Date
Title S 1+f1 +-,eWnC4Nan- 1.2- OL1r1L Rncw,
Description of Soil(s)
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator. • M 2V e r" Date of Evaluation It ) n e- 2
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed A S I Date 1 a [3 l� O (o
Inspections �,, /A
No. D� -��� v FEE ' U_
COMMONWEALTH OF MASSACHUSETTS
Board o Health 4kWM'1 MA. ! f
f / _...
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) lycomplete System
The undersigned hereby certify that t e Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( )
by: e5 Qe4 9
at
has been installed in/ ac�cor an/4 with the provisiojas ok 340 CMR 15.00 (Title 5) an th , a oved design plans/as-built plans relating to
application N D(fJ- �, dated/(Q Approved Design Flow (gpd)
Installer
1 dA (I'/ �� /�-•l Inspector: Date: _ Ins +
Designer: Jp �
Q 10
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The issuance of this permit shall not be construed as a guarantee d1at the system will function as designed.
No. � � Z-W���l4'9 � FEE
COMMONWE-ALT14 OF MASS HUSETTS
Board of Health, Ul:�G� , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby
at Z C
ited t ; Cons1ruct( )
Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Construction Permit No. C/,*- - O dated //-4-AZ
Provided: Construction shall be completed within `t„ Teti � of the date of this per it. All local con 'tions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date // `" �` B%ard of Health