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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 1q— ©©d . i✓ 7�1�L ✓ ��G- /" �n 9�1� " FEE 5 S", dV �_ TK f,1 W (LCA gamic -V COMMONWEALT14OFMASSACHUSEITS cx, ;W Lu l t Board of Health, YA'iL%%1OU ni APPLICATI®N FOR DISPOSAL SYSTEM CONSTRUCTIONPERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon() - 0 Complete System a<I Iidual Components Location LIZ 1 Owner's Name 1 �( Map/Parcel# Address CAPT, 4L� S. QpJ1 Lot# Telephone# Installer's Name j— © C(f) ` Designer's Name 9A5Z l U r la Address l 5 Cl *z HA xkoN Address ; R o �t, t Telephone# —L):U-- 0 Telephone# SQ-:� —,� >r Type of Building Lot Size 1� sq. ft. Dwelling - No. of Bedrooms �i Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) i gpd Calculated design flow 7 J � Q Design flow provided gpd Plan: Date � l l Number of sheets Revision Date Title IF _�� Description of Soil(s) t9 t�-' o1 r)? -o Ala `LO PA -41\-2t1 S:A N Soil Evaluator Form No. Name of Soil Evaluator A" VAp)J)e, Date of Evaluation *71 L C-17 DESCRIPTION OF REPAIRS OR ALTERATIONSn— 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 pWe the m in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date W, I 19b Inspections LI No. ba" � �ea --f,1 � ,(p 14 / r'^�4 � f� VII FEE k!5. 00 COMMONWEALTH OF MASSACHUSETTS �'e ,� Board of Health, ���7211 rI0 Ili MA. CERTIFICATE Of COMPLIANCE 69e),< i Description of Work:2<ciividual Component(s) ❑ Complete System The undersigned hereby certify that the -Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( J-,-Al5andoned ( ) by. at Lye -,IL -ed R has been installed in accordance with theo�2sions of 310 CMR 15.00 (Title 5) and th a roved design plans/as-built plans relating to application No. �� dated � /"(� Approved Design Flow—(gpd Installer CA `� ' c - --L G -l- � Z U �.k � �� Designer: bw\<' r 'i 1 U - C—t4�(!;' ((Ol Inspector: Date: f -a The issuance of this permit shall not be construed as a guaranfee, that the system will function as designed. No. ~L} FEE �-� 6 MASSACHUSETTS C" Board of Health, Q , MA. DISPOSAL SYSTEM STEM CONSTRUCTI®N PERMIT Permission is hereby granted to; Construct( ) at x-13 CA ice". Wel Left ( ) Upgrade f,e Abandon( ) an individual sewage disposal system Disposal System Construction Permit No. f � , dated as described in the application for Provided: Construction shall be completed within thxeeTemTof the date of this perm -i r�l local condit�ans must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date Board of Health. C �_