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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 04 1! C'� �i�� l I �'1✓V�l. ( / L��r� " r 1 ��_/ FEE' `V - COMMONWEALTH Off' MASS CHUSETTS �9 �� �` / Board of Health, Y "Moi PPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade AbandonO ❑ Complete SystemU.l-rndividual Components Location Owner's Name Map/Parcel# 6i 27 Address Lot# Telephone# Installer's Name pj(S Designer's Name 00 Address ddress PC? Telephone# Sb Telephone# _ Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ), Cafete { ) Other Fixtures ^ 2'� Design Flow (min. required) o� gpd Calculated design flow 0WDesign flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation 11 DESCRIPTION OF REPAIRS OR ALTERATIONS t ✓► The undersigned afire to install the above described Individual Sewage' Disposal System in accordance with the provisions of TITLE 5 and further agrees to o ace the 1. to eration until a Certificate ofeCompliance has been issued by the Board of Health. Signed 3 Date Inspections P-2-2--Ig `Z rrw�rej 4q, Ito COMMONWEALTH OF MASS C14USETT Board of Health, f�'lol� 1 , MA. , -- ' OtC. Qy`N!G$ CERTIFICATE Of COMPLIANCE t��= °� � 4 Z Descri tion of Work: ©4dividual Component(s)❑ Corn lete S System p� P ys The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),,Repaired (Upgraded ( Abandoned i by: !1'' . , -e'_: at \Ij 1��—r lea has been installed in[ccordanCe with the provisions of 3 CMR 15.00 (Title 5) and the approved des plans/as-built plans relating to application No.�A'd ted l Approved Design Flow4LV (gpd Installer Vols i � i\e' n � w Designer: I i2Y�it� ',AIV'62g Inspector: Date: The issuance of this permit shall noconstrued as a guar,ai ee that the system will function as designed. k- to' COMMON EALTH Of MASSACHUSETTS Board of Healtli, �� F t1C lv1 , MA. DISPOSAL SYSTEM C® STRUCTION PERMIT FEE Permission is hereby granted to; Construct( ) Repair(yade ( Abandon ( } an individual sewage disposal system at �" { o c /"' • as described in the application for Disposal System Construction Permit No., dated Provided: Construction shall be completed within ears of the date of this per nit. All local cond�*tiogs rust be met. `r1 r Form 1/25/S�Rev. Y96 A;M)Sulkin Co: Chadesl0wn, MA � �(ate �- �,��-Iyt� B and of H�oealth%�t f