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HomeMy WebLinkAboutApp-Permit-Compliancep©t o00 No.L�' COMMONWEALTH OF MAS ACHUSETTS FEE 4116" �oog� Board o Health, LAj=P IOU , A.M. � APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrad44-Abandon() - 0 Complete System �dividual Components Location 0 Sp © `f Owner's Name ��,� � 8�(Z,) .tV sx\ I T Map/Parcel# (Coto3 Address % C�'' Lb q,j N s5► > -S ()JI VI Lot# a Telephone# So TS - iq pL -t? ED Installer's Name ppDesigner's �'� is (��'� CoC.<Ip C g Name Address 1 AQbjjdjAclAddress p 6 , &,. ' Telephone# Qs- 113a- S O Telephone# 50, - 1-L - TOL Type of Building Lot Size Ysq. ft. Dwelling - No. of Bedrooms _i Garbage grinder( ) Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. r quire)d) `41 0 gpd Calculated design flow '330 Design flow provided �' gpd Plan: Date 19, b � � Number of sheets G Revision Date Title i f Description of Soilk Soil(,) A 8 or. ao N S- Lo A nr Soil Evaluator Form No. Name of Soil DESCRIPTION OF REPAIRS OR ALTERATIONS 1:05"5�k, L )r A44�%T CYM hbO(LDate of Evaluation k The undersigned agrees to install the above de cr'bed Individual Sewage Disposal System in. accordance with the provisions of TITLE 5 and further agrees to not to place em in a tion until a Certificate of Co plliiance has been issued by the Board of Health. Signed Date I Rh Inspections No. � ..: FEE s7 , 66 . COMMONWEALTH OF MASSAC14USETTS � �&-#-,00<32-5(o Board of Health, YAtLtti 001 -hl , MA 4, CERTIFICATE OF COMPLIANCE � Description of Work: &Indhidual Component(s) ❑ Complete System >41e z ' The undersigned hereby certify that the Sewage Disposal Systema; Constructed.,( ),Rep d ( ), Upgraded>(9Abandoned{ ) at G OCD Q 1 n) ST, has been installed i accorr ce with the p-r°�visions of 310 CMR 15.00 (Title 5) an ,,tth�he,,aa proved design plans/as-built plans relating to application No. 'T , dated Approved Design Flow r��(gpd) Installer CA -'-10 S, -1-b tP W10V- 0 J Q -- Designer: inspector: i nate: ^• [ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. 0 �y C' «' �. C)k) R_ r FEE 00 ! I COMMONWEALTH Of MASSACHUSETTS Board of Health, 7A"igm odro , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) UpgradeA Abandon( ) an individual sewage disposal system at L c as described in the application for Disposal System Construction Permit No/, dated / �f Provided: Construction shall,be completed within- �1 e years of he date of this permit. All local co ns must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date =� J ^� Board of Health