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Home My WebLink AboutApp-Permit-ComplianceNo. &O# W " I b 40738 COMMONWEALTH LTH ®F M ASSACITUSETTS Board of Health, _007-h MA. APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION TE 455.00 REC_R FIVE p Illy 2 4 ?016 L'to—spr Ap lication for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - omplete System ❑ Individual Components ocation —<--7 ��'f O O -e zzi zp Owner's Name Map/Parcel# Addresso11 Lot# Telephone# d c> cp /P, ,f �" J Installer's Name ;,.01 Designer's Name.e) tt3? Address Address �).t J✓� IvL,�G Telephone# ��/ p��{ �7� Telephone# Type of Building 30 Lot Size sq. ft. Dwelling -No. of Bedrooms Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) � � gpd Calculated design flow 3� 9 Design flow provided J' 9 gpd Plan: Date Number of sheets �' Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees not to lace the system in operation until a Certificate of Con fiance been issued by the Board of Health. . Signed Date A Inspections e tt.rr COMMONWEALT14 Of MASSACHUSETTS �w Board of Health, *g (Yrt t , MA. ` �`� CERTIFICA l ©f COMPLIANCE Description of Work: ❑ Individual Component(s) omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( )> Abandoned ( ) by: at r dk 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. f '`% dated? '/UApproved Design Flow (gpd) Installer r �f"ri ^ - ^ Designer:4.0_&,►Inspector: c. �OiG�.' y Date:J The issuance of this permit shall not be construed as a gua ntee that the system will function as designed. No.i6b(<-DC-1(o-107S9 1 ^6 LC -71 000P FEE 00 �i COMMONWEALTH OF MASSACHUSETTS Board of Health, V&rZ & 01 (Al , MA. DISPOSAL SYSTEM'CONSTRUCTION PERMIT Permission is hereby granted to; Construct(A-l"'Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at ''' �° ..s� „ ��Yi �' a'S 'e -e- 1" as described in the application for Disposal System Construction Permit No. .'` �� 'jdated Provided: Construction shall be completed within 4hfee-Tens of the date of this permit All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ) Board of Health