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HomeMy WebLinkAboutApp-Permit-Compliancer 7z� 1146 ROU E `,,'''pro FEE No. SO. YARMS3U 6-j, MAS 02664 COMMONWEALTH OF MASSACHUSETTS Board of Health, ilf%il�l�G��7 r� , MA. r APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade (e Abandon() - d Complete System ❑ Individual Components Location Z a Owner's Name 0,11 qlq Map/Parcel# 57/ / Address 2-7 Lot# 7 Telephone# Installer's Name Bm J �' Designer's Name �e/J Zo Addressr__ �Af %W I -I , / j. Address O1 JZ !3X2 6 s Telephone# 7 7 / —VJ0 Telephone# Type of Building — Re5;WeXZ)e, 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) 317a gpd Calculated design flow Il Design flow provided 3e/� gpd Plan: Date k4l::e% Number of sheets� Revision Date Title J% l )4 5;e4Jye /�19�I Z 7 Czwe 4W.41U34'1 Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS ORALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to noLto ce,. eration until a Certificate of Comp ' ce has been issued by the Board of Health. Signed Date RZ17, r Inspections No. CQMPONWEALTH Of MASSACHUSETTS FEE -7571 Board of Health, MA. COMPLIANCECERTIFICATE Of ' Description of Work: ❑ Individual Component(s) 2"Complete System The undersi ned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned by: © &&-i C� s , 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. dated F ' Approved Design Flow (gpd) Installer Designer: 1LOU"l-I Inspector: Date:(>�% The issuance of this permit shall not be construed as a guarantee that the system will function as designed.