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HomeMy WebLinkAboutApp-Permit-ComplianceNo. (C—),C), G L1 COMMONWEALTH Of MASS C14USETTS Board of Health, YA?= N.a kMi , MA. FEE Z�13 APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION /-Individual ERMIT Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) - Ll Complete System Components Location s ` ,cwee 4 Owner's Name 'i66 e601, Map/Parcel# —7 Address Lot# t/ Telephone# Installer's Name Co Q Cock Se X- TM peC tOn Designer's Name Address T-0, Be)s, 1%6 f�q" d Z,6 %y Address Telephone# 50? Z'70 TY00 7?Y--7 Z t— 2 Z Telephone# Type of Building 1` Dwelling - No. of Bedrooms Other - Type of Building _ -0S , P Other Fixtures Design Flow (mina required) Plait: Date Title Description of Sbil (s) _ Soil Evaluator Form No. gpd Calculated design flow Number of sheets DESCRIPTION OF REPAIRS OR ALTERATIONS c ev�ct I --loos- , The ung further Signed Name of Soil Evaluator cove � Lot Size No. of persons sq. ft. _ Garbage grinder( ) Showers( ), Cafeteria ( ) Design flow provided gpd Revision Date Date of Evaluation r 'n V( of 9 cawe escribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and in operation until a Certificate of Compli ce has been issued by the Board of Health. Date 16—°` /6 ins T14 � To 5, �� � �' �� l� � , -r ).--(r. - rA4< Wq)kv- ATv- k*- - No. COMMON LIN OF MASSACHUSETTS Board of Health, VAM)Ulli MA. CIMTI1FICATIE ©I' fflM I.IANCF FEE d _, 60 4- yt Description of Work; {a Individual Component(s) ❑ Complete System ti CC A The undersigned hereby certify that the ewa e- Disposal System;sitem; Constructed Repaired Upgraded O,Abandoned ciby od S O f at J� l f) ! ,has been installed in accordance wit the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. L' �. dated i c � i Approved Design Flow --`A (gpd) Installer 0 (CF 0 Designer: Inspector: d Date:"'' The issuance of this permit shall not be co>�strue as a guarantee that the system will function as designed. ` Oro No, �� � _ � QE Ct�� ��T1 C � IJ rJ I'- J FEE Y� s, Board c f Health, ( MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby ranted to; Construct( t( v� epair Upgrade( ) Abandon( ) an individual sewage disposal system at 2 Lt'Cat� f P �✓ as described in the application for Disposal System Construction Permit No. " dated '10, Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. Form 1255 Rev, 5/96 A.M. Sulkin Co. Chadeslown, MA Date J iJL Board of Health