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Home My WebLink AboutApp-Permit-Compliance(zQ No. 'Wry '/`�'�'��U A / 1 ~! DCJ/ �47 Ig -61, COMMONWEALTH OF MASSACHUSETTS FEE i " d* 2b 118 Board of Health, NM?N0 TW , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION %,I, ,jT 0 Application for Permit to Construct( ) Repair(4 Upgrade( ) Abandon( - & Complete System ❑ divi uat Componen� L r%, -- Location 3S Owner's Name 4"ggL7 90 /$) JL4 9-1) Map/Parcel# S,� 1 Z0 i Address SA "7 Lot# — Telephone# - Installer's Name �� 1(M,pA/ ,V h �l v� L((_ Designer's Name. D 6A/ Iy S [meq r/t� V Address 1 S Address ),�' S OCC t H131Z-j I Telephone# Sj y--3 L- SS 6 S Telephone# So-? L� 3 Z S3&_5 Type of Building DI 1 L unit Lot Size 10 000 sq. ft. Dwelling - No. of Bedrooms 2� sT4) Garbage grinder ( } Other- Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (mina required) U gpd Calculated design flow '530 Design flow provided 3 S�' ti gpd Plan: Date -. 1 /C)) 1 \7 Number of sheets i Revision Date Title S 17t= /�'(AV 0 f /ILOC17560 (0N"fl-A-,C7/0A/ Description ofSbil(s) /--1'6y? Soil Evaluator Form No. Name of Soil Evaluator Ji /`�� U ti Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS l SUV SS ( f>— - �� `f S' U )1v F7L-76V'r70>Z UA/) -Fl The undersigned a ees to install above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agree ton to pla a em in operation until a Certificate of m�orn©©pl' ce has been issued by the Board of Health. Signed Date GLV Inspections FEE ` No. OR bC. _ 'l.®1°Al"ll'UrNWALT14 OF MASSA'l.it7tUSETTS 8� C"� Board of Health, �_ o d , MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) 0 Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired O, Upgraded ( ),Abandoned ( } by: s'�-� K",v ICA UA7'lv;' L c C ` j�ttj tie k-mA-tJ Cq-)S-DZ, at has been installed itp,,acc dance with the provisions of;,7,0 CMR 15.00 (Title 5) and the aproved design plans/as-built plans relating to application No. 1 dated Jr�iApproved Design Flow,j (gpd) Installer , ti A, c, _ Designer: Q Inspector: 1 Date: The issuance of this permit shall not be construed as atee that the system will function as designed. No. i--�',',NFEE 450 COMMONWEALTH OF MASSACHUSETTS CA4 I zts Is Board of Health, MA- DISPOSAL A.DISPOSA . SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(-, ) Repair,(' ) Upgrade( ) Abandon( ) an individual sewage disposal system at 3 l (.U,-,Cz b le CD "? as described in the application for -' Disposal System Construction Permit No. , dated ••� � �� Ip %NUJ i Provided: Construction shall be completed within tkz�s of the date of this permit. *-local conditi must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA Date �.� % % a-oard of Health 3 /"