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HomeMy WebLinkAboutApp-Permit-ComplianceNo. BO�JJ�--i�%-�Z3� FEE i MA. /111)Y/Board of Health, �_ �e /�, APPLICATION FOP DISPOSAL SYSTEMCONSTRUCTION PEd I �al 41 Application for a Permit to Construct( ) Repair( -,/Upgrade( ) Abandon( ) - ❑ Complete System © Individual Components _ ,j/`r l Location 7 Owner's Name " Dd Map/Parcel# 00. !- Address /� . � ✓ Z� Lot# Telephone# Installer's Name _y y19 C,� Ora! Designer's Name Address 3s- Cam +4,-, - /-,/ fk 1 / /vlT Address Telephone# 6f 24rF� Telephone# Type of Building Lot Size sq. £t. Dwelling - No. of Bedrooms Garbage grinder( Other Type of Building No. of persons Showers O, Cafeteria Other Fixtures Design Flow (min. required) 22 gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil (s) Soil Evaluator Form No, Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS mea` -L,2d �"�` �JeC � D +Bar, The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the cyst eration Certificate of Compliance has been issued by the Board of Health. Signed e _ — 7 r'l� No. COMMONWEALTH OF MASSACHUSETTS Board of Health 1� 0 M4 4 MA FEE ( - 3 9-4 (4 CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s), ❑ Complete System The underlined hereby certify that the Sewage Disposal S stem; onsn•ucted ('�epaired ( ), Upgraded ( ),Abandoned by. L - C) I,, a at ..4.' has been instal}ed in accordance with the p oviston of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated �� Approved D ignp Flow (gpd) Installer�-7 Designer: ------ " Inspector:Date: 1 t The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. C= %-62-3 I -Dt60c NCS Savjec V -Delo! FEE /7 y Board of Health, / 0 DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission isherebygranted to;, Construct( ) Repair(grade( ) Abandon( ) an individual sewage disposal system at 9 Z 11� as :described in the application for Disposal System Construction Permit No. dated 3 t l 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. Chadeslown, MA Date 3 ! Board of Health