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HomeMy WebLinkAboutApp-Permit-Compliancepa'1 r No. V -SA COMMONWEALTH Of MASSAC14USETTS Board of Health, lVal:wAt-1-4 , MA. FEE ✓ " ' 1 v Z� APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon(: t Complete System ❑ Individual Components Location 2_3 Owner's Name Map/Parcel# L/ J �� Address Lot# S Telephone# Installer's Name / "AAe j10e Designer's Name Address�"�� Address✓ Il411- ly, Telephone# Telephone# aJ Z Type of Building Lot %GrL© Lot Size Dwelling - No. of Bedrooms 3 Other - Type of Building No. of persons Other Fixtures sq. ft. Garbage grinder �® Showers ( ), Cafeteria ( ) Design Flow (min. required) r3!/ gpd Calculated design flow %%® Design flow provided X3,33 gpd Plan: Date ®Number of sheets l Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS T-1/ le , ��, Q// The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees ton to lace the tem in operara 1-a Certificate of Com Hance has been issued by the Board of Health. Signed Date %� Inspections Y No. 7T / r% Description of Work: The undersigned hei by: Di D L at %.; &A FEE COMMONWEALTH OF MASSAC14US ETTS Board of Health, _Ya%e®ll�, MA. G F OF COMPLIANCE CERTIF ICT ❑ Individual Component(s) Complete System by certify that the Sewage Disposal System; Constructed ( ), Repaired *<'Upgraded ( ), Abandoned has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.�� "S / JL,, dated 12-/<% `Y tF-. Approved Design Flow (gpd) Installer Lc�i`7µ X-) 1/ S Designer: Inspector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. S'99'— 15o,_,�J Z FEE Board of Health, \®V DN , MA. 1 DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby anted to; Construct( ) Repair(I�Upgrade( ) Abandon( ) an individual sewage disposal system ZT /1J at y ,�C'd�.5 4l _ as described in the application for Disposal System Construction Permit No. V — , dated /2 -14 %F Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date G' ' / Board of Health ' - - " — — ,• �9'1 /^ / � .mom �. �" C ,... _..�. i" � /qtr' G'�n ii .GJ' . � ,.-... w �