48 Application & Permit 2016 Jo
COMMONWEAL OF IASS,>€IIUSETTS
VV Board of Health, 1 O iG/'1 MA.
.ALE CalCATION FOR DISPOSAL SYST r CONSTRUCTION PERMIT
application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - U Complete System Individual Components
Location
Owner's Name
4
en
Map/Parcel#
Address
17
Lot#
Telephone#
Installer's Name
Designer's Name
/a
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Aret S
Address
Address
Telephone#
Telephone#
Type of Building 1,ot Size sq.ft
Dwelling-No.of Bedrooms 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 OF REPAIRS OR ALTERATIONS
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 Date
Inspec
,C /Jd .
Of
r ii irfin <
/J`5
/ 5
COMMONWCfEAL:RI OF,MASSACIIUSETTS
( ��` i'�'I
IIT.
Board of Health, ', t ' "
CERTIFICATE OF COMPLIANCE el1 u, }
Description of Work: filndhidual Component(s) ❑Complete System
The undersigned herebb ertify that the Sewage Disposal System; constructed ( ),Repaircdk Upgraded ( ),Abandoned ( )
at /!' c e tY r/ /,-4,
has been installed in accordance with th/provfsionsyf 310 CMR 15.00 (Title 5) and the approved design pia s/as-built plans relating to
application No /.? dated 7/ [ / 'IT APlmmt-d-DMIT o '
Installer r'- F ,• -' %
Inspector: : i / 'Date: "a%
Designer :! , '-- ,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No
COMMONWEALTH OF MASSACHUSETTS
MA.
�e ���� m� Board of Health, -6‘���
j/1 ms 44 DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
FEE
at
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Farm 1255 Rev.5r96 A.M.suixin ea.chEesoxnw Date Board of Health