112 Application DW /Certificate of Compliance„•0740/6-i �D od
FEE
COMMONWEALTH OF 1 ASS HUSETTS
Board of Health, / 10 4(G.,firiv , A1A.
APPLICATION FOR g
DISPOSAL SYST I CONSTRUCTION PERMIT
pplication for a Permit to Construct( ) RepairUpgrade( ) Abandon( ) - ❑Complete System Individual Compo ents /
SePi”c 4.)X
Location �4a ,ej-41-/B4_,--./ Owner's Name Ejt S5/' e,� 1
Map/Parcel# Address
..s�,..iiCp
Lot# Telephone#
Installer's Name Designer's Name J
Address Address a
‘57%( /1/////0/0/11eAli/
Telephone# Telephone#
qpe of Building Lot Size sq.ft.
welling-No.of Bedrooms Garbage grinder( )
ther-Type of Building No.of persons Showers ( ),Cafeteria ( )
ther Fixtures
esign Flow (min.required) gpd Calculated design flow Design flow provided gpd
an: Date Number of sheets Revision Date
itle
escription of Soil(s)
til Evaluator Form No. Name of Soil Evaluator Date of Evaluatio
ES F PAIRS OR ALTERATIONS
41,// 1 / / /'J
he undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
irther agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
gned1:/e Date
6�
ispections
c).. /6-// FEE /1 /
COMMONWEALTH OF/ MASSACIIL SETTS
Board of Health, Ai/rlb I'1/TU/Li, MA.
CERTIFICATE OF COMPLIANCE
escription of Work: Individual Component(s) ❑Complete System / 1/e
: 74
he undetsi ed he by certif that the Sewage Disposal System; Constructed ( ),Repaired' Upgraydd ( ),Abandoned( }
r. 7 > /l l P� / r /
%1/22 �i,,, ,_ / ,,/,- /�Gr�t,I
is been installed in a cord. c, with the provisions9f 310 CMR 15.00 (Title 5) and the approved desigiu pla s/as-built plans relating to
tplication No. _ 1 - , dated -,,,K)/,,b, . Approved Design Flow (gpd)— 4,e /-7)/ (,c2,-./.. /..4�
istaller G/' �� e
)
! '
esigner: -- Inspector: _� Date: /O 2 /
_
he issuance of this permit shall not be construed as a guarantee that the system will function as designed.
a. FEE
COMMONWEALTH OF MASSACHUSETTS
r;1 F 1 o P Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
ermission is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
as described in the application for
isposal System Construction Permit No. , dated .
rovided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
n 1255 Rev.5/96 A.M.Sulkin Co.Chadeta,'MA Date Board of Health