439 Application & Permit 2009 No. :{Cr)`I -- '7 FEEL
COMMONWEALTH OF MASSACHUSETTS 5 a'
.tv Board of Health, lJ4 Phi ra tM , ALA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑Complete System
1 i dividu alComponent s
1 Location L-139 t J J(nui/ ( ("fed) Owner's Name Pa 11 f L 1nn�n D
,
Map/Parcel# Address 431 T/41 3 l dit I T VII L e I
Lot# Telephone# Lf( - p,
K --n - 7* I
Installer's Maine '' -f--- J� - � Designer's Name
Address X - y' Address
hqh./'! ']^-
Telephone# ,- q 2 I Telephone#
Type of Building -->1)-11')ftp A0 ti U1 Int Size sq.ft
Dwelling-No.of Bedrooms J Garbage grinder()
Other-Type of Building No of persons Showers ( ),Cafeteria ( )
Other Fixtures
Design Flow (min.required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets_ Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator - Date of Evaluation
DESCRIPTION OP REPAIRS OR ALTERATIONS — ! u' ' -
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 Compliapce has been issued by the Board of Health.
Signed ,�} - /� ( - t " ate h /' ? / _
Inspections
No-
COMMONUV£ALTII OF MASSACHUSETTS FEE
Board of Health, /' ._.,L, MA.
CERTIFICATE OF COMPLIANCE f
Description of Work: ❑Individual Component(s) ❑Complete System be 4< �J yt TICS-y=+'V
The undersigned,tier/ehy certify that the Sewage Disposal System; Constructed O,Repaired ( ),Upgraded ( ),Abandoned ( )
by: L/ d,t..Uff/ r-LA �✓�
at -U' °i d a-e. ,C:',
has been t lled in accordance with the p otisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating t+
application No_ _ , dated 9; /r Approved Design Flow (gp(1)
Installer (I 4,V-4 A.c■ y r,) n a —
Desigien !//;� Inspectoe lJ� - ` '�^ i=A— Date: • / 417/4
The issuance of this permit shall not be construed as a guarantee that the will function as designed.
No.
FFE COMMONWEALTH OF MASSACHUSETTS Pd c-6-11s'ioo
Board of Health, r,1!a t ,.a.vl o}, r-, , MA. .l -d 9 o')
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( '��C Jpg
( ) Repair(i) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
Disposal System Constcnetion Permit No. ev,., 2 , dated -(.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Fon 1255 Rev 5296 nu.amem co.sn:resimm 41A Date t —4 "--? Board of Health -