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HomeMy WebLinkAboutApp-Permit-ComplianceNo. R_,- dd33wa ��� moo 4 f /-,�,r�,�1. Board of Flealth, APPLICATIONFOP DISPOSAL SYSTLM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(�bandoa( ) - ❑ Complete System,— ndividualComponents Location 10 S11-1 Owner's Name - L e ( jjl) / Map/Parcel# Address SOOTh a S. C GU Lot# Telephone# e> � Installer's Name ©VQ, CQ Designer's Name &KS R V -P11' !J to rw Address -d it Address P-0, 80 ` P) S Telephone# ® ..4 3 533, Telephone# �'� ,., %jy/ Type of Building _ Lot Size �0Li G _ sq. ft. Dwelling - No. of Bedrooms Garbage grinder( ) Other -Type of Building No. of persons Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) lip gpd Calculated design flow 33c), Design flow provided gpd Plan: Date ! 2! . J l Number of sheets Lf Revision Date Title Description ofSoil (s) a1 A A - hor,zo^j LC A&l -V% 'tq a hO':`6le)AD - Soil Evaluator Form No. Name of Soil Evaluator ?bate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS "r N S T 03 The undersigned agrees to Inst the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to Ql a system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections No.1�� FEED COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. I�8 CERTIFICATE Of COMPLIANCE o 3 2 Description of Work: .Fa i�iidividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,Abandoned by: 1''l' p 5 1... r 1�.� �a at al has been installed in accordance with the provisions of y31.0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated - - / Approved Design Flow "(gPd) Installer�t Designer: d2l!t t'_ E ter, W, Inspector: �¢:. 14-4 .e°`t. 0 •�.i �.,,, 4i Date: % The issuance of this permit shall not be .construed as a guarantee that the system will function as designed. No. 11 E 1 ' ! "� 1 (.~). - FEE COMMONWEALTH Of MASSACHUSETTS ik Board of Health, I A-le—MO Cn-)+ , MA.. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to;, Construct( ) Repair(.,) Upgrade Abandon( ) an individual; sewage disposal system at 10 Z Q�a_C'- as described in. the application for Disposal System Construction Permit No. ''� ; dated we Provided: Construction shall be completed within thTeTY- a -Fs of the date of this perm•t. All local con4tions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date j ''? Board of Health '