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HomeMy WebLinkAboutApp-Permit-ComplianceNo. W DC'ts--60S3 bt DM —t --000g17 FEE COMMONWEALTH Off' MASSAC14USETTS t Board of Health, Y©C , MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct( ) Repair( ) Upgrade( AbandonO ❑ Complete System aRndividual Components Location Owner's Name Map/Parcel# l Q f Address Lot# 3 Telephone# Installer's Name Designer's Name CA Address y �.. ddress V Telephone# 150I;c 5/0;L 4Lt Telephone# Type of Building Dwelling - No. of Bedrooms �CS L J Other -Type of Building No. of persons Other Fixttn-e. Lot Size sq. ft. Garbage grinder { Showers ( ),'Cafeteria{ ) Design Flow (min, requited) 3 3 0 gpd Calculated design flow Design flow provided gpd Plan: Date �� Number of sheets Revision Date Title /n__� Description of Soil(s) -fZ 44M8 Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS n �C� �_ - . _ {" 5 AS `AQ:M, • A8 , 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 place the item in operation until Certificate of Com fiance has been issued by the Board of Health.. Signed L Date Inspections No. FEE Board of Health, Agtd 01_, MA. CERTIFICATE Of COMPLIANCE ,.� ,Description of Work: 94ndividual Component(s) ❑Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded. Abandoned ( ) r at has been installed in aaccor4apce with the provisions; 310 CMR 15.00 (Title 5) and the pproved design plans/as.-built plans relating to application No.,�, dated °l [ Approved Design Flow =(gpd) + Installer Designer: tiYl Inspector: �' Date: The issuance of this permit shall not be ,construed as a guarantee that the system will function as designed. 1 ( t� l t No. � v l 1 s-rt � �_ 3.:.> ,.'S U � (. �... �. $\.,.} FEE, Board o Health, �'E l� MA. f ��� DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(/ Upgrade( ) Abandon( ) an individual, sewage disposal system at 9.'� lst-9 as described in. the application for Disposal System Construction Permit No. dated - /�. Provided: Construction shall be completed within three years of the date of this petit All local condi 'ons must be met. % /�i r' Form 1255 Rev.5l96 A.M. Sulkin Co: ChadeslOWq, MA Date Board of Health s