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HomeMy WebLinkAboutApp-Permit-Compliance` , 9-64)03Yf- FEE' �o� DC—iB—ba�3 COMMONWEALTH OF MASS CHUSETTS j ( Board of Health, �G-i�181i1 MA• sF: m APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PE MI ' ; A JPF ti'catiOn for a Permit to Construct(' ) Repair( ;) Upgrade Abandon( omplete System O Individual Components ;1 ) c L cation i v U I (A) � Owner's Name p �� Ja��'+ ap/Parcel# C Address O U T� So '11-4 A Lot# Telephone# 6CD " Installer's Name RO (ger-T Designer's Name 8 � Address fo t VAI)-v Address 4 6 4®' 1163 . rsAA Telephone# O _ Telephone# Type of Building Lot Size ri• sq. ft. Dwelling - No. of Bedrooms 3 Garbage grinder( Other - Type of Building No. of persons Showers ( ),'Cafeteria Other Fixtures Design Flow (min, required) 1 C2 gpd Calculated design flow 32n Design flow provided gpd Plan: Date �p I e+Q 1 Number of sheets Revision Date Title �u N CV Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator AAA+ l V 6P Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS 3: I)6S%R L 1 �+ 1 Cl ©t`� ' A ��• 01 0" 13 x tA 1 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to plac emmiin�operation until a Certificate of Compliance has been issued by the Board of Health. Signed / Ai► / Date C!f FEE �!✓ If COMMONWEALTH OF MASSACHUSETTS f%v Board of Health, ` r�C- rJa��i —, MA. CERTIFICATE OF COMPLIANCE Description of Work:; D Individual Component(s) ❑ Complete System t The undersigned hereby certify thatch Sewage Disposal System; Constructed( ), Repaired ( ), Upgraded Abandoned ( )` by: e r\ Vl� e d (Z- C at 1 has been installed • 1 accordance wit h`t ie rovisions oo 0 C R 15.00 (Title 5) an th proved design plans/as built plans relating to application No. _y/, dated Approved Design Flow (gpd) Installer (:'1- Y;?, 0 way # Designer: 4�� : t $ v t lr I fs 1 h.) Inspector:Ir—f c i2 ' - � " '< Date; — — The issuance of this permit shall not be construed as a guara�,}r f` a that the system will function as designed. No. 4 ).l'C --I e bc)53 FEE ram: COMMONWEA Board of Health,-Y1�it"aU 11 MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade{") at Abandon( ) an individual: sewage disposal system as described in. the application for Disposal System Construction Permit No. A6 dated 0 !�! Provided: Construction shall be completed within t4"s o�the date of Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date` /� /� ,Board of Health -,Z i