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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 5 FEE dd gouDc-t-7-219co COMMONWEALTH OF MASSACHUSETTS &forezo j 7 f YUM0t� MA. Board o Health, , PPLICTI®N FOR DISPOSAL SYSTEM C�NS RUCTI®N PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( bandon( ) - Complete System ❑ Individual Components Location AV�5 Owner's NameAli 115 Map/Parcel# f AddresscA b N rJ04 y Tl L Lot# 33 Telephone# �( (o _ G 3 3 ` 9144 Installer's Name dv Co�N Designer's Name RAve>(K Address (� H 1(i Address Ro Q(�� 1 (fl a N 1S l 09 ff la Telephone# -- 0 S-3 O Telephone# SQ - Ll— (DLj Type of Building Dwelling - No. of Bedrooms Other - Type of Building Other Fixtures Design Flow (min. required) !' �C) gpd Calculated design flow Plan: Date Number of sheets LI Title Description ofSoil(s) A Soil Evaluator Form No. D SCRIPTION OF REPA U YVI. `Q CIA A, O.N-s Name of Soil Evaluator ORALTERATIONS :Z tJ S I'Q. L �V= Lot Size i sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided'( gpd Revision Date K[41K4WUJffiW�"R", UPWATAMMMM Wate of • r 9 . 1000 00,L ,zab The undersigned agrees to install thea ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not t lacethe in operation until a Certificate of Corn fiance has been issued by the Board of Health. Date 0 Signed F f No. t�jCi?"a ..:. .,.,.. � ✓r --� Ir- i 0 Vr FAE 7 �1 / ®MM®NWIA I:TI ®� MSS��IUS�TT �> r Board of Health," Vf�9&0(T , MA.4w./—17 CEP.TIFIC , ©f COMPLIANCE tion Descri of Work: ❑ Individual Component(s) onent(s).ote System P The undersigned hereby certify that the Sewage DisposaOUR_l System; ' Constructed ( ), Repaired ( ), Upgraded Abandoned ( ) T R . S at has been installed in accordance with the provi!ylp-of 3L0 CMR 15.00.,(Title 5) and the approved design plans/as-built plans relating to application No. r dated i ` J > Approved Design Flow -(gpd) Installer C . NiZ (5 TG f HZl2 0 LAZ- ,-7 .}n -- Designer: VS5 12N" L(14 tN E� i2i lJ(J"' Inspector: Date: d' ' '� ' f 7 µ„ The issuance of this permit shall not be construed as a guaradtee that the system will function as designed. <>o1,b��c0c; 1 c�: o` No.e'"-�'�.AS%_j F�?Ut3c-�tT f, 06 Ca. FEE 55,06 /7--4 C®MMON LTH Of MASSACHUSETTS Ck* o01e2JD Board of Health, Yag&oU —I* DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( at Upgrade (el"*Abandon ( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No., dated Provided: Construction shall be completed within {�tli'rrs years oLf the date of this perpiij.;All local conditions ondi ns must be met. Form 1255 Rev. 5196 A.M. Sulkin Co. Chadesbwn, MA Date! > Board of Health ~