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HomeMy WebLinkAboutApp-Permit-ComplianceNo. boww'-(G-11140 COMMONWEALTH Of MASSACHUSETTS FEE i br, �a 44 3 M e In f j�,jMQ � MA. Board o Health, , ,J APPLICATION FOR. DISPOSAL SYSTEM CONSTRUCTION PERMIT E Ap lication for a Permit to Construct( Repair()o Upgrade( Abandon( - ❑ Complete System ,Individual Components ocation It C-:.4TZ-= WM Owner's Name d w7piiA Paw A 5 ap/Parcel#Address ,95 ,0 &- Igo p Lot# Telephone# Installer's Name D�Cd,( �- aj;� Designer's Name. Address iS3 Address Telephone# o V — 47 7 ..-9TS 'j 7 Telephone# Type of Building R G6 a6&uT 1,4L.. Lot Size Dwelling - No. of Bedrooms Other - Type of Building No. of persons Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soil (s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator G A.)e r -r- sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Design flow provided Revision Date Date of Evaluation gpd To 5qT�cz-AV l The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed f^\ _ "' Date (0- d19 -;L01�A Inspections / "- fI��FEE 00 CONI MONWILALT14 OF MASSACHUSETTS Board of Health, YYIW=M 0 ()TW MA. 0 CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired }, Upgraded( ), Abandoned ( by:. CAPEWrb rrr EAJ1E-A?AQQZ WC' at j l G47-6 IAIAV has been installed in accordince with the rov�sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.-�`CA �r! dated' Approved Design Flow (gpd) Installer y[Q Ca,?f%r- C/CJ1 1akVlGl`=iC Designer: Q/A Inspector: The issuance of this permit shall not be construed as a guaz:a tee that the system will function as designed. Date: No. 6cwpc (o 4 t 4o CAPEW l De COMMONWEALTH OF MASSACHUSETTS Board of Health, YA-AM a U + , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE *' ©Q 356 Permission is herebygranted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at 11 �:;i&IC: KIAY f Disposal System Construction Permit No. ' / ` _ , dated C -36 as described in the application for Provided: Construction shall be completed within three years of the date of this permit. Notal condition�t be met. -�l, 2, - - Form 1255' Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date oard of Health