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HomeMy WebLinkAboutApp-Permit-ComplianceNo. vV I FEE C®MM®N LAS CtRWiS 1146 ROUTE 28 9_1�01 Board of Health, S©. YARMOt1Ta-1_ MA 02 APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) - ❑ Complete System UkIdividual Components Location1°j T I_oAloC/®d,�r7 `��(° �o Owner's Name S V L L f P 41to, Map/Parcel# AF_ e6 3 Address 3 ��' ,[ d .vim ��►ti ,�� -f yg Lot# Telephone# r 3 Installer's Name �fiie Designer's Name Address '3,:5- Address Telephone# So r . / / ,f - -,XrGs Telephone# Type of Building Dwelling -No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil(s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets Name of Soil Evaluator Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS le 'r 0L 'v- C F 1 'd-04 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr s to not to place the system ' operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Cl Inspections No. c�.2 - �� FEE COMMONWEALT14 OF MASSACHUSETTS Board of Health, V,�/9?'Opt-'1 , MA. CERTIFICATE Of COMPLIANCE Description of Work: 61ndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4� Vpgraded ( ), Abandoned ( ) by:1�[�16 (011 % C0 -3SG 4 57- L 101/X, gG. at 3 Y s`2 Ol 0 A.' A 0007,4 -D �D/ AZ , yo has been installed in accorda ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application o. 0 2 -�� dated Approved Design Flow (gpd) Installer �.� . .•-` �. .r Inspector: Date: l0 The issuance of this permit shall not be construed as a guafantee that/the syst m will function as designed. No. D 6 U FEE C®MMOINWEALT14®F MASSAC14USETTS Board ofVealth, '12./yf�- MA. DISPOSAL RYSTEM CONSTRUCTION PERMIT Permission is hereby jgranted to; Construct( ) R at 3 yoL C3 6r tDisposal System Construction Permit No. r( 4,4 Upgrade( ) _ Abandon( ) an individual sewage disposal system A_ as described in the application for dated11'd Provided: Construction shall be completed within three years of the date of this per . All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date / 0 3 _ board of Health (-�C_