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HomeMy WebLinkAboutApp-Permit-ComplianceNo. I r _ b© 11 tea'�Ie - W 4AOFIE455, OD 800c-mq-61ge COMMONWEALTH OF MASSACIIUSETTS GP/ V 1'1! F � Board of Health, Y A-12WO114 MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for Permit to Construct( ) Repair( ) Upgrade Abandon( ) - 5-Complete System 0 Individual Components Location ctyi PP 14 rell" < w Owner's Name or' �, Map/Parcel# '10 o Address �tsl i �� - Cv f .J Cl r id Lot# Tele 'hone# Installer's Name S'T r d (Z. C' _ ►J Desi ner'sName _. g ik r Address 1''.L� 1�G�,ie b53 s�'W5%cr. ®^ , Address _ Nao, Cal 0 Telephone# ., '. .. G Telephone* z _ Type of Building Lot Size 01 9 9111 sq. ft. Dwelling - No. of Bedrooms 0 Garbage grinder { ) Other - Type of Building No. of persons Showers( ),Cafeteria( ) Other Fixtures Design Flow (min. re wired) gpd Calculated design flow Design flow provided gpd Plan: Date / Number of sheets 3 ReAsion Date Title Description of Soils) d ��f'tYT-1--QA9-C— 6A.nn,S�� 4brtZ.ra /V A4-(Ce►N-m Soil Evaluator Form No. Name of Soil Evaluator A MINC►1 /Yd Ale- Date of Evaluation !Wj )'� DESCRIPTION OF PAIRS OR ALTERATIONS NS T`ckl l r c � '� r 1 rqlj K r The undersigned agrees to installa above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not top _ system ' peration until a Certificate of Compliance has been issued by the Board of Health... 17 Signed Date Inspections 6� q� A q- CItS- COMMONWEALTH Of MASSACHUSETT n Board of Health, ). &MQUnA , MA. i llK. CERTIFICATE OF COMPLIANCE d Description of Work: 0 Individual Component(s) 8 C omplete System The undersigned hereby certify that the Sewage Disposal System, Constructed O, Repaired ( ), ` pgrade Abandoned ( ) by: fZ r � t`e . er at. Ct,r i has been installed in accordance with til jisions of 310 CMR 15.00 (Title 5) and the a proved design plans/as-built plans relating to application No. dated L4e . Approved'Design Flow (gpd) Installer {a_": , 0 O�(L C.--0-(�'-1 S-MpilreN_ A,1 Lf // Designer:- f' jA\S5 \/ EFV- f�QC1{!"' Inspector: L/ Date: . f The issuance of this permit; shall not be construed as a, guarant at the system will function as designed. !! �j No. (C FEE 1r' COMMONWEALTH Of MASSACHUSETTS dt* (1 I Board of Health, i4,(L1Nlb Lmi, , MA. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgradel?q Abandon( ) an individual sewage disposal system at t 0 1 trr._.� l � p j fit a C-fn' reN C, I-C�1� as described iii the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed withi s of the date of this permit. All local conditions must be met. Form 1255: Rev. 5/96 A.M. Sulkin Co. Chadeslown, MA Date (' Board of Health ' J �+ f