691 Application & Permit 1998"pai atiun Cm
FEE I ✓
COMMONWEALTH ®E MASSACHUSETTS
Board o/Health, CWRrNAPI PT OA) MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permit to Construct( Repair Upgrade( ) Abandon( ) - O Complete System yy Individual Components
pc of Building �'7
welling.No.of Bedrooms pe / --5/64J X0/1 3
tiler-Type of Building
tiler Fizmies
esign Flow (min.required) 3 gpd Calculated design flow
Number of sheets ne
an: Date
itle 5 D, 5 z..-e,:ripiion ofSoil(s) l.�u • • Fs d S S _ n,
til Evaluator Form No.
Name of So
No.of persons
4
Lot Size 250 sq.ft.
Garbage grinder(Hd
Showers( ),Cafeteria ( )
Design flow provided 4' / 5 gpd
Revision Date
Date
/3 ern
Evaluation 3/2 ti 4 p
ES(:RIPTION OF REPAIRS OR ALTERATIONS
he undersi
ether agre
OPP
'pet duns
all the above described Individual Sewage Dis osal System in accord
the systeht in operation until a Certificat- .f r om G we h been i
•
14\1`
Owner'sName�'RA 16 DMU(5
Address 6,9/1eE37i4Mp7OU RMP AIOeTNAmProO A
uion l
11
'Parrcl# /2- / %6
Telephone# 9/3- sr6 - r$53 0/oroo
Designer's NameD9u/D F KFATES
Installer's Name 3 / '
t..1.44
Address
Address/07 Ru5SE/J ST SOS,Lab,414 0/375
Telephone#
'J
Telephone# / /3_ 665-- 7670
pc of Building �'7
welling.No.of Bedrooms pe / --5/64J X0/1 3
tiler-Type of Building
tiler Fizmies
esign Flow (min.required) 3 gpd Calculated design flow
Number of sheets ne
an: Date
itle 5 D, 5 z..-e,:ripiion ofSoil(s) l.�u • • Fs d S S _ n,
til Evaluator Form No.
Name of So
No.of persons
4
Lot Size 250 sq.ft.
Garbage grinder(Hd
Showers( ),Cafeteria ( )
Design flow provided 4' / 5 gpd
Revision Date
Date
/3 ern
Evaluation 3/2 ti 4 p
ES(:RIPTION OF REPAIRS OR ALTERATIONS
he undersi
ether agre
OPP
'pet duns
all the above described Individual Sewage Dis osal System in accord
the systeht in operation until a Certificat- .f r om G we h been i
•
N„ / (-7
COMMONWEALTH OE TASSA ,TIUSETTS FEE �,
Board of Health, L aQ rotifrvi !J , MA.
CERTIFICATE Of COI PLLANCE
Description of Work: )(Individual Component(s) 7 Complete System
The undersigned here certify that the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( )
by: aCl(si 1...)41)) s
at fe J wt c7-7.4.42...441 rkm a Ask
has been r Iled in accordance with def.pi( ioi of 10 CMR 15.00 (Title 5) and he o9prored design plans/as-built plans rela
application No. ylated rs ! . Approved Design Flow J7S (gpd)
Installer J/�1,4, f/l4- ,e 4 /-
Designer: ThAt.; E KiPi' °f Inspector: r 7 i'� � -ti1 n Date: 3/ 7/
' The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
C// c' FEE/ 9 G
COMMONWEALTH Of NASSA ITSETTS
Board of Health, l(
DISPOSAL SYSTEM CONSTR- CTION PERMIT
Permission is hereby granted to; CCoystruct( )/Repair((/ Upgrade( ) Abandon( ) an individual sewage disposal.
at @ ( 1J CAA C1/241,i 4jm rY' jF as described in the applicath
Disposal System Construction Permit Nc ' is-SY ,dated 5�yi/1
Provided: Construction shall be completed within three years of the date of this p qI'mt All loca con nymust be
Form 1155 Rev 5/96 AM_sultln Co Boston.MA Date 0/1;2/Board of Health �� /L