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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6000-P-37% FEE 46 100 COMMONWEALTH OF MASSACHUSETTS c*4303` Board of Health, V%-ejI4OVT?+ MA. y�dJ� � `7, APPLICATION FOR�' SPOSAL SYSTEM CONSTRUCTIO�_I�PERM IT Application for a Permit to Construct( ) Repair UpgradeO Abandon( ElComplete System 'Individual Components Location F- Owner's Name d-,, O Map/Parcel# v Address -16 Lot# Telephone# Installer's Name n �� ? -; < � .4, LT; signer's Name Address] 1 MCI, it ddress lawTelephone# SOC V10 -77Y727, 22-'/l Telephone# Type of Building 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) gpd Calculated design flow Design flow provided Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation _ gpd The undersign, ees to ' t the abo rib ed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ages n tto 1the sys% eration until a Certificate of Compliance has been issued by the Board of Health. Signed �� Date �c/ 17 Inspections No. bo (A DC -I -%-3i 9 t7 COMMONWEALTH OF MASSAEIJr� � �� �� � 30eq Board of Health, riOVT)f , MA. CERTIFICATE OF COMPLIANCE Description of Work: Individual Component(s) ❑Complete System The undersigned hereby rtify that the ewage Disposal System- Constructed ( ), Repaired Upgraded ( ),Abandoned ( ) at J t has been installed in acc r •ance with the provi ions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. % dated -:j Approved Design Flow (gpd) Installer i,` A 0 C1 Designer: Inspector:Date: The issuance of this permit shall not be construed as a guar a that the system will function as designed. No. (a�l�t- �_3^% y C.O� SSC {(�5 FEE S5,C3© Board of Health, )�CQQ MA. DISPOSAL SYSTEM C NSTRUCTION PERMIT Permission is hereby granted to; Construct( } Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at f i s (� f as described in the application for Disposal System Construction Permit No. dated .f Provided: Construction shall be completed within drrmisi s of the date of this perm�t�ocal con tions must be met. Form 1255 Rev. 5/96 A.M.Sulkin Co. Chadestown, MA Date - ,)- /Board of Health i