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HomeMy WebLinkAboutApp-Permit-ComplianceN3c-17-38G5� P46114�V o—Q x-0615 Board of Health, �,y r MA. APPLICATION FOR 7POSAL SYSTEM CONSTRUCTIOYndividual I�MIT p lication for a Permit to Construct( ) Repair'pgrade( ) Abandon( - C3 Complete System Components �3 I ocation Owner's Name MGA. Map/Parcel# >e Address Lot# Telephone# Installer's Name Cep c (, ��` ;�� Designer's Name Address . -o- *66K,+46b 1, L(, zW Address Telephone#YC rj©© 1 -77V 1,7 Z*ZCj g I Telephone# Type of Building Dwelling - No. of Bedrooms _ Other Type of Building _ Other Fixtures Design Flow (mina required) Plan: Date Title r Description of Soil (s) _ Soil Evaluator Form No, OF The uni further Signed Inspections Fm gpd . Calculated design flow Number of sheets Name of Soil Evaluator Lot Size No. of persons sq. ft. _ Garbage grinder( } Showers( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation ,4etx4�,yq ! Qe r �tSzLLrt ,Cr eBFV dial Sewage Disposal System in accordance with the provisions of TITLE 5 and ntil a Certificate of Cox>lpliance has been issued by the Board of Health. Date�� No. �c --1-7 S (:o S-t/C.K. �'r �f� FEE i b,.! 00 7� C®NlMONW.EAILTH OF MASSACHUSETTS Board of Health, L1 D0 , MA. CERTIFICATE Of COMPLIANCE Description of Work: 4/individual. Component(s) Ll Complete System 404 - The undersigned hereby certify that the Sewage Disposal System; C nstructed ( ), Repaired ( Upgraded O, Abandoned ( ) by:'r ),_ _ l OCA J J, at 1 t3Ci� C� has been installed in accordance with the application No. ��`7 '7 dated Installer --� - C {OR �i ,C-- : C-a,70er ?o /I -Sion of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to Approved Design Flow (gpd) Designer: V -- Inspector: -- Date: _ The issuance of this permit shall not be construed as a guaray ee at the system will function as designed. No. i, 1 -�Yf c3rCj �C,4PE COD SGa nc /,AZ MOA r 77 COMMONWEALTH OF MASSAC14USETTS Board of Health, _ y oxm� , MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT FEE 3� Permission is hereby granted to; Construct( ) Repair( ' Upgrade( ) Abandon( ) an individual sewage disposal system at JziOw(�ewa�rr X DA) as described in the application for Disposal System Construction Permit No. `� %% , dated � �-7 Provided: Construction shall be completed within t �f th date of this pe�rnt. All local conditions must be met. r Form 1255' Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date-2�1�oard of Health 1 s/