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HomeMy WebLinkAboutApp-Permit-ComplianceNo ev, FEE COMMONWEALTH OF MASSAC14US ETTS f � Board of Health, � 1 t- -„e `_,_,_, BVI!© MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT A plication for a Permit to Construct Repair( ) Upgrade( ) Abandon( - XComplete System ❑ Individual Components :Location s7 CoL_6UAuE pig Thi Owner's Name MtGH AJn %F=”/LA T. Map/Parcel# 7616 (6 AtZM �u7"!-i Address Lot# j q Telephone# (508) a 5"Ci " *c0 0 9 Installer's Name t9R 1HN i4i• 1 SSL- Ri Designer's Name Donald W. Moncevicz, P.E. Address 017 T'dwN GMOOk R..D, Address Civil Engineer Telephone# y'o! ^ 40 Pond Street "7'%8 _ Q���' d 6. x-13 Telephone# West Dennis, MA 02670 Type of Building /� s�O�N 71f,� AL. `� d il) 394-05'09 94-05'09 Lot Size _ O y' sq. ft. Dwelling - No. of Bedrooms 3 Garbage grindeerr (/ Other -Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min, required) a? :30 gpd Calculated design flow Design flow provided 3.302 gpd Plan: Date 44A `y ! , (� ! % Number of sheets Revision Date TitleGRr31�r it Description of Soil (s) �/��' �/�'r�}W / /v Soil Evaluator Form No. Name of Soil Evaluator — ate of Evaluation 7.20 I % DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr s to not to place the gs;tn in op tion until a Certificate of Compliance has been issued by the Board of Health. Signed i Date I U 1-7 �.; Inspections No, C®MMONW-EAILT14 OF MASSACHUSETTS FEE i5S. 00 J N e . `. 342-1 Board of Health, y"Mo kmA , MA. c..A ! t CERTIFICATE Of COMPLIANCE ID Description of Work: ❑ Individual Component(s)Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( Repaired ( ), Upgraded O, Abandoned ( ) by: has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. e, dated Approved Design Flown & gpd) Installer B e_w� & c V=d S s u r-� G- Designer; elwAL[2,"WaaC_'yt G7_ Inspector: .P Date: The issuance of this permit shall not be construed as a guarantee that tKe system will function as designed. r /—(4 05 Z FEE T / -- COQ' MONNMLT14 OF MASSACHUSETTS CA. Board of Health,�je�_?ffi PE* , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(Repair( ) Upgrade( ) Abandon ( ) an individual sewage disposal system at . r7 Co" d�t�d'Zy,� PA-, 'H 1 �' YkmourT 4 as described in the application for Disposal System Construction Permit No.2— dated �o�► Provided: Construction shall be completed withinher th ' ate of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date'Board of Health