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HomeMy WebLinkAboutApp-Permit-Compliance&O4DC,_n'0 038O©Oo2%�. � FEE MMONW LTH OF MASSACHUSETTS G�� �oIl � /�� - Board o Health MA. PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT pplication for a Permit to Construct( ) Repair( ) Upgradee<AbandonO - omplete System ❑ Individual Components Z Location kaoeOwner's Name Map/Parcel# ;2 /" %4, 3 Address Lot# Telephone# Installer's Name9L esigner's Name. Address P% Address Telephone# Telephone# Type of Building Dwelling - No. of Bedrooms Other Type of Building,_ Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (mina required) a- gpd Calculated design flow Design flow provided 2--f:50- -gpd Plait: Date Number of sheets _ Revision Date Title Description of Soil (s)� Soil Evaluator Form No. ff Name of Soil Evaluator Date of Evaluation l 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 es to not to place the system in operation a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections' Or No.—= COMMONWEALTH Of MASSA ' TTS EE Board of Health, V A-V , MA. ` CERTIFICATE Of COMPLIANCE oq/�8/17 Description of Work: ❑ Individual Component(s) Qleomplete System The•undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded�,(s�, Abandoned ( ) by: r at ! ""c has been installed in accordace with he provisions of 310 MR 15.00 (Title 5) and approved design plans/as-built plans relating to application No. / .7 -' 7r dated :7- —� 14-1"7 . App(ro�ved Design Flow (gpd) Installer Designer: 6 .�i*�„y40 /s° !`..g.. . Inspector: f jiC.�,�'.�'''a�d Date: The issuance of this permit shall not be construed as a guar e` that the system will function as designed. 17-176 COMMONWEALTH OF MASSACHUSETTS FEE Board�of Health, �J PW JMn MA. ofSPOSALVSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade (Abandon ( ) an individual sewage disposal system at ~.f < " as described in the application for Disposal System Construction Permit No. /:z, dated Provided: Construction shall be completed within trP-, Wte ateofhthis per i . All local conditions must be met. Form 1255Rev. 5/96 A.M. Sulkin Co. Chadestown, Mn Date r Board of Health f 9,n !/ /- .4-- _ / r- Ir --- '1--1 sib - -