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HomeMy WebLinkAboutApp-Permit-Compliancepp nD / 1 No. W 04-1114' 7 v t 1 FEE S5 -y 00 upCOMMONWEALTH Of MASSACHUSETTS s 3� f Yama� MA. �'�°9 Board o Health, , APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION KRMIT Application for a Permit to Construct( ) Repair( ) Upgrade�bandonO - Q-e-0-4lete System ❑ Individual Components Location 55 h d 1 QA 5 Owner's Name Q(,_�L Map/Parcel# toAddress Lot# Telephone# o Installer's Name IkaGJQ.. omd Wvdl Q,.- Designer's Name _. Address 3 5 VW y` �� ��� Address S� Telephone# 500 Gt . 91 1 Telephone# Type of Building Lot Size d_ 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�� Design flow provided 3 J gpd Plan: Date Number of sheets Revision Date Title Description of Soil (s) _ Soil Evaluator Form No. DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator 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 agr a to not to pla a the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date[,Zq Ito Inspections No. 1X=A —111"4-7 COMMONWEALT14®f MASSACHUSETTS FES Board of Health, YA 0 MA. ` k# q -70 a CERTIFICATE Of COMPLIANCE _ Description of Work: ElIndividual Component(s) eElZomplete System The ui;i0ersigned hereby certifA that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (..);'Abandoned ( ) by: rV1 0 i 1r1V-1 at has been installed in accord ce with the proit}sion,, of 0 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to application No. �/ ,dated . Approved Design Flo,^ i (gpd) Installer �-a( '4! '1 t7 i-"'" a V Designer: 'S ' Inspector: Date: The issuance of permit shall not be construed as a guaraa•f ee that the system will function as designed. FEE - / -- 0 COMMONWEALTH OF MASSACHUSETTS Ck* 57©q Board of Health,A � Qt2M MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) 1Re pair(�) Upgrade(,Abandon( ) an individual sewage disposal system a P P at c t -' t IV ll l M " as described in the application for Disposal System, Construchon l e4nit No el dated Provided: Construction shall be completed within yrs. f the date of this permit. l local conditipns must be inet. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date ``'' J feBoard of Health 1