198 Application & Permit 2015 COMMONWEALTH Of MASSACHUSETTS
/V
Board of Health, d/477 Y»//0/CM )MA.
CATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
o Construe f RepairC) Upgrade Abandon( ) -,Complete System ❑Individual Components
FEE (!3D
ti Sink
se of Building g/c�'1/7//f-1 r in e /ioin e /5����G d ra
elling-No.of Bedrooms VI✓
aer-Type of Building V '/
sign Flow (min.required) J/O k 4e gpd Calculated design flow T 90 Design flow provided �AO gpd
m: Date 670Z/20 CC Number�offt sheets / Revision Date
n
le ,rA:Af c: s y5-n- / ' /✓'e5/4,c) %-V 2 /Ida r /rs/7/rsr/i
scription of Soil(s) ett9c %�rrA N/S4 ` ,L/ 9& stye_kt/ /Vi2 '
II Evaluator Form No. // Name of Soil EvaluatorLc)J C5 ' L/� 'kte of Evaluation 3/i y/eoci
coximeTf/ nSON J O Conott4
9/3 Sb3 X39
2// 3 297 97oe
[ 8)r.0 Q00�s p Garbage
Lot Size
a. 5 75 ffe
grinder '` '
(Sn%.f/6['C G%4/%% r 1'L' No.of persons V Showers (µCafeteria yy+/,
her Fixtures /CC?l-L iq rn %
3SCRIPTION OF REPAIRS OR ALTERATIONS
re undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther es of to p ce e system in operation until a Certificate of Compliance has been issued by the Board of Health.
gned Date OS
spectious
oration /240,ge ( 41,17//57-4
Oner's Name %ii /L/Z ,€ i/5i 74 77
lap/Parel# /9B ,vLVFsi224 uAnn
+ u
Address (Cis 5 (C rhfl I
Q U/2_
.ot# /U%nA/�/I/p O`) w,Y
z%
Tele hone� 9/9 -3b0 /S'7o
astaller's Name
Designer's Name JJ/LL,/' 44 V St/UJ1
tddress
Address /e OtPOr toA,d 14445C z-A: -/L r 7-r-
'elephone#
Telephone# j 4 rlf9 /3/ 7
se of Building g/c�'1/7//f-1 r in e /ioin e /5����G d ra
elling-No.of Bedrooms VI✓
aer-Type of Building V '/
sign Flow (min.required) J/O k 4e gpd Calculated design flow T 90 Design flow provided �AO gpd
m: Date 670Z/20 CC Number�offt sheets / Revision Date
n
le ,rA:Af c: s y5-n- / ' /✓'e5/4,c) %-V 2 /Ida r /rs/7/rsr/i
scription of Soil(s) ett9c %�rrA N/S4 ` ,L/ 9& stye_kt/ /Vi2 '
II Evaluator Form No. // Name of Soil EvaluatorLc)J C5 ' L/� 'kte of Evaluation 3/i y/eoci
coximeTf/ nSON J O Conott4
9/3 Sb3 X39
2// 3 297 97oe
[ 8)r.0 Q00�s p Garbage
Lot Size
a. 5 75 ffe
grinder '` '
(Sn%.f/6['C G%4/%% r 1'L' No.of persons V Showers (µCafeteria yy+/,
her Fixtures /CC?l-L iq rn %
3SCRIPTION OF REPAIRS OR ALTERATIONS
re undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
rther es of to p ce e system in operation until a Certificate of Compliance has been issued by the Board of Health.
gned Date OS
spectious
7
FEE(//{57;
5 COMMONW£ALTII OF MASSACHUSETFEE(//{57;
Board of Health, O IL/74 d , MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) }l
Complete System
The undersigned hereby certify that the Sewage Dis osal System; Constructed ( ).Repaired y),Upgraded SO,Abandoned( )
/ /
at /12-7;c in cc J/ Pr- i. c�
has been tolled in accordance with the prordsiops of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating
application No. .;(o'4-' F . dated 4/ la 1/h . Approved Design Flow 'J(gpd)
Installer 'OA/ i ,t, .1� 7�1fJ �tLi i
f Inspector: Date:
Designer: �'iinI /i (E ���-
The issuance of this permit shall not be construed as a guarantee that the system will function as designed. /�''
No.;110 J FEE 1/7//
COMMONWEALTH OF MASSACHUSETTS
Board of Health,_ ,/ 7/Jt /r,/%%//A./ . AM.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby grante to; Construct( Repair Upgrade( ) Abandon( ) an individual sewage disposal sys
//cQj as described in the application
at 1,i 7/Le° f,`/ /ALr!
/ -W5 6 ,dated 6;7 .
Disposal System Construction Permit No.
Provided: Construction shall be completed within tt/ree years of the date of this permit All local ggnditions must he in
Form 1255 w..5/96 AM.Sulkin co.wrimeasnaA Date 47;7y7/9 Board of Health -A--- _