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HomeMy WebLinkAboutApp-Permit-ComplianceNo. g�--('\� �`''" FEE 130*DC—I-7_0 100 COMMONWEALTH OF MASSACHUSETTS C"Orvq Board of Health, VA- I?wQT'A , MA. PPLICATION EOI, DISPOSAL SYSTEM CONSTRUCTION PERMIT Ap icati n for r it to Construct( ) Repair( ) Upgrade (,)�Abandon( ) - ❑ Complete System 491ndividual Components Location RCP Owner's Name Tix-- N A W—A a Map/Parcel# Address R� .1L (z,:jfkW0A1 Lot# Telephone# _ K - � I Installer's Name �'i4% ur Designer's Name P-0je c" Com' NSC?4 AddressRQ, 90IfU Address a,12.0 IS Telephone# 6 Telephone#50'g-,3( Type of Building Dwelling- No. of Bedrooms Other - Type of Building _ Other Fixtures Lot Size OC I— sq. ft. Garbage grinder ( ) No. of persons Showers( ), Cafeteria ( ) Design Flow (min. required) � % C� gpd Calculated design flow Design flow provided 33 6 gpd Plan: Date 1) -3 h Number of sheets est Revision Date Title Description of Sbil(s) _ Soil Evaluator Form No. Name of Soil Evaluator A d-3 �(014 DESCRIPTION OF REPAIRS OR ALTERATIONS L N �x�Ll D-- P5 6JC / The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to nottop the tel in operation until a Certificate of Co limn Signed %cue has been issued by the Board of Health. y Date Inspections I 17 b? /Z t --1,j & No. FjOWDC —0-0 1i'`.?0 FEE h± 7---- C®MMONEAITH OF MASSACHUSETTS ®C) Board of Health, �� )MA, CERTIFICATE ©f COMPLIANCE Description of Work; idividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired ( ), Upgraded ( ),Abandoned �() by:/ at -- +Jr- 4' - �P has been installed in accordance„rith the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. '� `;,dated!. Approved Design Flow (gpd) Installer a Designer: 6u`1-,,5 ctc�IC i _ Inspector: F Date: The issuance of this permit shall not be construed as a guarantee that the systeft will function as designed. J No. B Q 4 y — C:) J () C) (e0. . FEE $-2zaa COMMONWEALTH OF MASSACHUSETTS Board (f Health, t M4 , MA. DISPOSAL SYSTEM[ CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) UpgradeAbandon ( ) an individual sewage disposal system at d L.=_i as described in the application for Disposal System Construction Permit No. , dated,I �- Provided: Construction shall be completed within tb1=U14rs of he date of this -- permit. All local conditions must be met. Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown, MA Date Board Health MOV ,aGy" i /,G�° ra.e..,t'r4`