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HomeMy WebLinkAboutApp-Permit-ComplianceNo. ft l� X � —101(o r` } FE �j ��D 7 00 _� 09N / C© � ASSACH SET S � 4 Board of Healih, MA. APPLICATION FOR DISPOSAL SYSTEM ST CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade �Abandou( ) - O Complete System - Individual Components Location Owner's Name rf Map/Parcel# Address 1(0 ^V -Li -y/, Lot# Telephone# 2) - "19 ` 1�45J Installer's Name 0/h� fht( '1"--- Designer's Name Address 60 d0kkk0A Qd Address Telephone# UP Telephone# Type of Building 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) gpd Calculated design flow Design flow providedgpd Plan: Date Number of sheets Revision Date Title Description of S'oil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agr es to notto place a syste ,in operation until a Certificate of Com liance has been issued by the Board of Health Signed Date Z F, 24 Inspections x 444i No. I^� _. ( FEE ' t- 6 COMMONWEALTH OF ki,4 10693 Description of Work: The undersigned her by, ('41ric� ural at �I f i-) ti F 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. I ,dated /} J-7. Approved Design Flow - (gpd) r Installe-ti Ft . t�wDesigner: ------Inspector: Date: The issuance of this permit shall not be construed as a gu- ateethat the system will function as designed. FEE_ W 7- �` COMMONWEALTH Of MASSACHUSETTS 41 i(306-3 Board of Health, Y A -R -MO JD4 , M.A. DISPOSAL SI STEM C®NSTRUCTI®NT PERMIT Permission is her9 y, granted to,; Construct( ) Repair( ) Upgradeflf Abandon( ) an individual sewage disposal system at �� �(?f' N }Jt as described in the application for Disposal System Construction Permit No., dated Provided: Construction shall be completed within three years of the date of this permit. All local con 'tions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. ChaileStown, MA Date L- ' Board of Health Board of Health, Hj�L-rr]Q V iii' MA. CERTIFICATE OF COMPLIANCE ,rf eIndividual Component(s), ❑ Complete System / '-7w 0 by certify that the Sewaa Disposal System Constructed O , Repaired ( ), Upgraded Abandoned(