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HomeMy WebLinkAboutApp-Permit-Compliance' 1 T © 2 Q ,/� No ° BOA! yC C7-7�� / 9� Zif,4, l%* 70C FEE' �� —o/ COMMONWEALTH Of MASSACHUSETTS Board of Health, �&g O&74 MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( JQ Upgrade( ) Abandon( ❑ Complete System vidual Compo encs j t ` LLD PA Location Oee9 tAJ Owner's Name C p/zo (/1 _ �Q Map/Parcel# '� J G Address 1e✓e-e & ✓R ��t+Q �� Lot# Telephone# Installer's Name /� G Designer's Name AddressN%/ SI p"13 Address Telephone# — — Telephone* ' Type of Building Lot Size sq. ft. Dwelling- No. of Bedrooms Garbage grinder { Other - Type of Building No. of persons Showers O , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Sbil(s) Soil Evaluator Form No. Name of So&Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS Qin 5 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to n place the in over 'on until Certificate of Com liance has been issued by the Board of Health. Signed Date InspectionsA.,0 /e ' �C CtU e�, [ 1t 8 COMMONWEALTH Off' MASSACHUSETTS , .--r,7 ' '-:):Cad Board of Health, �1� 0ir �� CERTIFICATE Of COMPLIANCE Description of Work: 'Individual Component(s) ❑Complete System. � The undersigned hereby certify that the Sewage Disposal System; Constructed ), Repaired), Upgraded ( )> Abandoned ( } at r� , ` ` ' 4< -Pw has been installed inaccord nce with the provisions of 0 CMR 15.00 (Title 5) and the approved design/plans/as-built plans relating to application No.,__ dated._C>�'� r �Approved Design Flow- (gpd) Installer J)1:T Designer: Inspector: t �`� fil Date: The issuance of ibis permit shall not be construed as a guarantee that the system will function as designed. No. c"'i 21 t{ C� �� J )` t iii( �.aP.. FEE COMMONWEALTH OF MASSACHUSETTS S� 00 Board of Healtli, VA21'VI 01 MA. DISPOSAL SYSTEM CONSTRUCTIONPERMIT Permission is hereby grantedto;, Construct( Upgrade ( ) Ab at E/ v--/a//vi owj 't- /(' ---,i,,,r `, ` Disposal System Construction Permit No,/ `'"1'/ .,dated '!5-'" 7• . Cs an individual, sewage disposal system as described in. the application for Provided: Construction shall be completed within three years of the date of this pertni; -local conditions m be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. ChadWown, MA Date —�—7 7 `'Board of Health (__� `°�=r'J Lam' ✓ �0��