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HomeMy WebLinkAboutApp-Permit-ComplianceoH-Dc-4ro--6 1-78 i�--I ��9 W 16 -497 COMMONWEALT14 Of MASSAC14USETTS FEE $,5,5,00 ck*-zqz (o ca I Board ofHealthYKtti6i OLJ�TH HEALTH DEFT . 1146 ROUTE 28 APPLICATION FOP, DISP00ALAWWWOXWRUCTION PERMIT (�_- 1 5 8ppI ation for a Permit to Construct Repair() Upgrade( ) Abandon( ) - ❑Complete System dividual Components Location O 8. \ Owner's Name Map/Parcel# 92165 Address 2U C&W%ellRd BeCh Lot# ' 3 Telephone# UO34�1 0420 Installer's Name T W, N' Inc Designer's NameMman Finwo-een'oo .Address Vl� M1` R � Address -19. Mi Telephone# 5 Telephone# 2 Type of Building Lot Size ft. Dwelling - No. of Bedrooms 3 Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (n Plan: Date + Title phi mo gpd Calculated design flow Design flow provided gpd Number of sheets Z Revision Date' it A —I (\1 J Description of Soil(s) see man Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS S C. C Date of Evaluation e undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agre ton t to laldif Vstem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date -L� Inspections A No.COMMONWEALT14 Of MASSACHUSETTS TtC Board of Health, yA9-MOOT S MA, CERTIFICATE OF COMPLIANCE Description of Work: -0<1vidual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O,Repaired ( ), Upgraded`f Abandoned( ) at NO d e-# CU N 5±h'F_' - T" has been installed in accor n-c�e with the rovision f 310 CMR 15.00 (Title 5) and he p oved design plans/as-built plans relating to application No. / dated 'w� �YApproved Design F ow (gp/00'r Installer "°( L iz / O`�(/� j✓u r' Designer: M042 N EN6 OJE9 l N6 Inspector: tJ � Date: The issuance of this permit shall not be construed as a guaraAee that the system will function as designed. ; No.o' VDC--leo-U 1-7 FEE 1F' 5!5, W COMMONWEALTH OF MASSAC14USETTS 2-cl 2- Board of Health, YP,'tz Ni OI)%)-�- MA. DISPOSAL. SYSTEM CONSTRUCTION PERM11 Permission is hereby granted to; Construct( ). Repair( ) Upgrade Abandon( ) an individual sewage disposal system at l �1G ,BACON 5T)�6ZE7 f as described in the application for Disposal System Construction Permit No. �((,.i ' /© 7, dated �r'f f Provided: Construction shall be completed {�withinrs othe date of this er . All local co ditions must be met. t5 /'/f%�J Form 1255 Rev: 5/96 A.M. Sulkin Co. Boston, MA Date YBOard Of Health 1...� A.�1�'�'�,,'.�"