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HomeMy WebLinkAboutApp-Permit-ComplianceFEE Oa O COMMONWEALTH OF MASSACHUSETTS 44-4 SY9 3 Uj Board of Health, P�RN1(1 V , MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERM, IT p ication for a Permit to Construct( R pair( Upgrade( ) Abandon( - 0 Complete System 0 Individual Components I cation Owner's Name ,�� �a re— Map/Parcel# ` / Address S�R e o Lot# Telephone#, ?7,9,. Installer's Name `T� e0�1 1--e-_ AW1. Designer's Name. Awn Address V'6 Address Telephone# �7Q`�� �. �� !�d',� Telephone# Type of Building Dwelling - No. of Bedrooms Other Type of Building _ Other Fixtures Design Flow (mina required) Plan: Date Title Description of Soil (s) _ Soil Evaluator Form No. Lot Size No. of persons sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) gpd Calculated design flow Design flow provided gpd Number of sheets Revision Date Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS R- C P Lc,-�'� j36Y l©GCp l��-t R i 5012 !The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n�tla��ystem " operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No. /7-129 C®�[� ONWEALTII OF MASSACHUSETTS Board of Health, Y 2, OO ,.NIA. FEE ,5 �Q2--�I.JS5 73 CERTIFICATE Of COMPLIANCE GYIn0 Description of Work; div dual Component(s) Complete System The: undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) at C' SiaG.i ✓� ,aJ _ has been installed in accoa ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to rd application No. dated -" -- % Approved Design Flow - -- (gpd) Installer Asa �n _��.c1r._'�-�'` d �'✓�_ __ n \ �1.-� Designer: �d/.J -C Inspector: � P���_ Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. 1 'I /")-J, COMMONWEALTH OF MASSACHUSETTS Board of Health, V i4{-M0Q MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE 6*4 toss�3 Permission is hereby granted to; Construct( ) Repair ) Upgrade( ) Abandon( ) an individual sewage disposal system at, ' �L�a� tG frS iet/.. as described in the application for Disposal System Construction Permit No. dated '"�7 Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadestan, MA Date tG �0 Board of Health — � ra r'% /C n �- 0