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HomeMy WebLinkAboutApp-Permit-ComplianceNo. f/ of iO l7 13LD �- 16 -60G -78S- FEE '! S I 00 Board of Health, i/}� res" APPLICATION FOR DISPOSALS STLM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade Abandon( - ❑ Complete System $individual Components Location / © Owner's Name 'DOA aL Q Q C 40S 4 e Map/Parcel# / liL Address 7 G •P fD11 1 Lot# Telephone# Installer's NameG" t- E-,<c-oru 4 1 Designer's Name Address t� ( Address 93 9 Telephone# Ile' Telephone# Type of Building l e. -s f owl �, Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required Plan: Date gpd Calculated design Number of sheets Lot Size sq. ft. ' Garbage grinder ( ) AA No. of persons Showers ( ), Cafeteri S ) Design flow provided �M-�-!' gpd Revision Date Title Description of Soil(s) r Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation The undersigned agrees toNstall the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and furtherto lac the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed s o not Date 6-13 No. COMMONWEALTH OF MASSACHUSETTS FEE 0 0 Board of Health, , CERTIFICATE Of COMPLIANCE Description of Work:ndividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired r16,Upgraded ( ), Abandoned ( ) at �7014 e 21 C---- D (AI , V AZ0 u has been installed in actor vice with the p�°�Zsions�of0 CMR 15.00 (Title 5) and th pprove desi ng_lans/as built plans relating to application No.-Z6� dated `^e -`1� / b . Approved Design Flow (gpd Installe y- t/ -J� � ((it !/'t "� �t��n1' l� � A� / Designer: Aibi y � Inspector: 6 Date: The issuance of this permit shall not be construed as a guaree that the system will function as designed. No. !moo i %� (� - �� !`u lig ESC SIA i►NG �C . FEE . J . 00 COMMONWEALTH OF MASSACHUSETTS cA* 3q -2-(o Board of Health, Y A � =Mo lam ' DISPOSAL SYSTEM CONSTRUCT N PERMIT Permission is h/I reby granted to; Construct( ) Repair(/ ) Upgrade ( Abandon ( ) an individual sewage disposal system at 1 1 4,4\ JR-1-� ��_ Y AP",14 o U U as described in the application for Disposal System Construction Permit No. 16 r , dated i,�, 4 Provided: Construction shall be completed within three ye the date of this permit:'IAll local c, nditt ns must be met. /' /f �f' Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadeOwn, MA Date i.g -I (� r,/ C Board of Health01 ���