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HomeMy WebLinkAboutApp-Permit-ComplianceNo. C^ F tO G Io �4�i�� Ay Gr- FEE $650 / 7 47 COMMONWEALTH Of MASSACHUSETTS Board of Health, ��ilv�0 (�%' , MA.® Y TENT CONSTRUCTION PERMIT � 7 APPLICATION FOR DISPOSAL S S S Application for a Permit to Construct( ) Repair( ) Upgrad Abandon( - ❑ Complete System -tT!Individual Components Location -1//mere j La wrenu Co Owner's Name 0 f- Map/Parcel# cel cO'R kO4- 7 Address 17 GE0 Lawfdp�- S , agmp0M Lot# Telephone# Installer's Name 13j' f JX LCl V ct f t o n Designer's Name T/ '� Address I y- `reCt b&, -f Ln 1FU E e s { ac u Address o 1� g 1 W, J�bzala Telephone# 5 0 8 -4 i ._ Telephone# '794 •— I Type of Building Dwelling - No. of Bedrooms Other - Type of Building No. of persons Lot Size sq. ft. Garbage grinder( ) Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) 1313 gpd Calculated design flow Design flow provided gpd Plan: Date ��' Z Number of sheets a_ Revision Date Title Description of Soil(s) _ Soil Evaluator Form No. Name of Soil Evaluator ' i-lah� Date of Evaluation 0-116w. DESCRIPTION OF REPAIRS OR ALTERATIONS 1© CL lox, (Z ) tq 10 j 00 �r l U) a rn bets The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr to place the min ration until a Certificate of Compliance has been issued by the Board of Health. Signed Date 0 2 2.0 ` t Je Inspections COMMONWEALT14®L NASSACHUSETT 0t-- Board of Health, Y/ti^7Q./j/i d c)-rh('7CERTIFICATE Of COMPLIANCE ' � `�!� ` Description of Work:individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded�;Ibandoned ( ) by: ti i t I `� a at 4 ~ f — 1 f-. irrj ! `t1� ' i t' r C - c- 2-1-j d i (T )! r, 7 ) i has been installed in accordance with the provisions of 310 CMR 5.00 (Title 5) and the pproved design plans/as-built plans relating to application -No, 17 " t f -7 : dated /7. Approved Design Fla (gPd) Installer �� � , ,1 �' • : f l� -°'�"i,' / ,r Designer: Inspector: Date: The issuance of this permit sliall not be construed as a guar4dtee that the system will function as designed. o o.•c�.� —_oo0001100,>0C,0aooae0010.,jou000("011000-1111 eo ocu oo o o 0000_ 00 ubo 000 o o o e o n e o o o o o o o o 3 o o o 0 o o r o o 000 00 00 o o o a o o o o o C, � c`, ti -u � , �b<S; No. 'PC) VA �l ' 4 � 4 � � to � � s �" �"% �-AiC.�i V , FEE COMMONWEALTH Of MASSACHUSETTSj,,4 5 ► ta 3 Board of Health, ®i-� DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) at ( ) an individual sewage disposal system as described in the application for Disposal System Construction Permit No. /7 , dated ` '/,7 Provided: Construction shall be completed within tbxe.+e&f the date of this pertt. All local conditions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date ✓� Board of Health ` �°