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HomeMy WebLinkAboutApp-Permit-ComplianceNo. BoVmc-t (o " ((NZ� io/e�-47� V LD "` ko —00-7 I' Z"-7 FEE 16,14 COMMONWEALTH LTH ®F M ASSAC14USETTS Board of Health, yagmat , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair (✓<Upgrade( ) Abandon( ) - 0 Complete System O Individual Components Location 33 .sJ /1 G7 Owner's Name c)CAr<3_ C r1^naC Map/Parcel# li Address ' G �( Lot# oc c.,' . -0o o�);ou..._ou u_ Telephone# 10 - I j I +_L Installer's Name, �' e0. J� t 0,(\ Designer's Name C L Erl) `j AddressCa �« 0. Address c3 afrh P Telephone# 3 Telephone# 1, oZ Type of Building Rc51 e L r\:� t o -N 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) 3 gpd Calculated design flow Design flow provided �v_ gpd Plan: Date Un It. 1 L Number of sheets ` Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS l DD f i 1 D S T ^ 1-4 1 O _9B Off( - Z H 1 o 600 y/ C- Z 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 Date/1 Inspections No. 001+x 40 ^ I Z FEE _ 60 r ` COMMONWEALTH LTH ®F MASSACHUSETTS G 1kV Z_ Board of Health, _ 49M O U7 -N , AVIA. CERTIFICATE Of COMPLIANCE Description of Work: 0 Individual Component(s) R omplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired V, Upgraded ( )> Abandoned ( ) by: at has been installed in accordance with the provisionso,rrf;310 CMR 15.00 (Title 5) and application No. / , dated Approved Design Flow' Installer XC --A V'xl 10 ClfSl 2t ' r (gpd) design plans/as-built plans relating to Designer: _. ')n e .sJ /1 G7 l✓ r L.i Inspector: i / Date: r' The issuance of this permit shall not be construed as, a guaran ee that the system will function as designed. < <:, n.+ ,�u�, :, �. •vo: ouu >oo no r. cuovc. .<, ,.,ni, ,a .moo.,., ._.,�._ _ �_._, v._, �occcc � ,., ',; ,,. .oc.. c..000c , c' " c ,o.,,,,„ oc c.,' . -0o o�);ou..._ou u_ No. = 10 - I j I +_L G -X CO ATi G N FEE is A _ /65 COMMONWEALTH LTH ®F MASSACHUSETTS Board of Health,V"MAIMt , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair (X Upgrade( ) Abandon( ) an individual sewage disposal system at Disposal System Construction Permit No. i l '� , dated 277 ' r as described in the application for Provided: Construction shall be complej�d within t1 -wars of the date of this permi . All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co`. Chadeslown, MA Date / /-To. Board of Health