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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 0 C-49 ."' 2-9(q �7- 0V- 55001 1—e 6L,DW-,s-66558-7 COMMONWEALTH Of MASSACHUSETTS Board of Health, Y IMA. FEEes-6t-00 .- /7j - � APPLICATION FOP, DISPOSA STEM CONSTRUCTION PERMIT A plication. for a Permit to Construct( ) Repair( ) Upgrade Abandon( - O1 Complete System ❑ Individual Components Location p a G Owner's Name 3 -,c, 006,0 3 Map/Parcel# 0j- Address Lot# 0,CC) Telephone# Installer's Name 6A-, Designer's Name PPWf L 0VU-PI • AddressAddress S` v 1-40it-> g i , Telephone# t3� G Telephone# C,= - Type of Building Dwelling - No. of Bedrooms No. of persons Lot Size sq. ft. Garbage grinder { ) Showers ( ), Cafeteria Calculated design flow er r-`-1 Design flow provided' J rl-"k- gpd sheets Revision Date iAr The undersigne grees to install the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and furtheir _ not to place the system m operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date ' l�U' c OUB✓�[ G C� Inspections --o No.t^ _�i` � ei C~ 4 G� ` � " ! FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, (kms , MA. CERTIFICATE Of COMPLIANCE��- Description of Work:. U Individual Component(s)Tete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( ) by at 12 0)ZV 2� has been installed in accordance with the pro vis ons of 10 CMR 15.00 (Title 5) and the pproyed design plans/as-built plans relating to application No. , dated I Approved Design Flow (gPd) Installer MAA J&PJJS6S Designer:-Dejti)M C44,©s= rlhi! Inspector: Date:_ The issuance of this permit shall not be construed as a Wantee that the system will function as designed. No. : l.� _ r) FEE COMMONW EALT14 Of MASSACHUSETTS Board of Healtli,n (, , MAA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is herebygranted to;, Construct( ) Repair( ) Upgradep Abandon( ) an indiyidual,sewage disposal system at Disposal System Construction Permit No. k--77 , dated Provided: Construction shall be completed within� three years of the date of Form 125j Rev. /96 A. , Sulkin Co. Chadeslown, MA Date r/ ! _ Board of Health P,100 as described in. the application for r1 All local conditions must be met. �„