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HomeMy WebLinkAboutApp-Permit-Compliancep� 02 Q(�, &-iT L9 �� �) 332No. Ivb DC -t �-U?-8�v 7 �j .o ;) FEE.. _ O MMONWLTH Of MASSACHUSETTS �1oH Board of Health,k MA. r 1_� APPLICATION FOR DISPOSAL S STEM CONSTRUCTION PERMIT Applicationfora Permit to Construct ORe air OUPgrade Abandon( O❑ Complete SYstem,11�dual Co m onents Location60 67 [ b&=QV P-0 h. Owner's Name S"i'Pao O Map/Parcel# –I Address R O. boy, 69 Se'—w P44t � Lot# 1 Q�'s Telephone# Installer's Name` &J76-M-PAUS &S Designer's Name V C E /PeF4,1 xj(::-,, 17J <, Address (,5 Address 2�vCAAM , T E t �L Telephone# 50-2 ,4 `1 Z -& 'T 1 Telephone# 562_;l_'7:3 - b-31 7 Type of BuildingLot Size q. CaF� -" s ft. Dwelling - No. of Bedrooms Garbage grinder Other -Type of Building No. of persons Showers O, Cafeteria Other Fixtures Design Flow (min, required) Plan: Date l & - I i- - oLo (� Title 4::0 64R Aixi S�tceC gpd Calculated design flow Number of sheets Description of Soil (s) LOAmt%( S Odub e 14, " - LtEDlv,%c 5o(Mb Soil Evaluator Form No. Name of Soil Evaluator K AM '0 DESCRIPTION OF REPAIRS OR ALTERATIONS iii v— "S -L V& I�4hets t-('-l0 0-9O)C TO Lacs) ARC 3.(C>tAz49595 tx Design flow provided ,3 S5 t D_ , gpd Revision Date I ' Date of Evaluation The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tg not t ace?e system in operation until Certificate of Compliance has been issued by the Board of Health. g I C—�� " lL Signed Date Inspections COMMONWEALTH LTH OF MASSACH SETTS 134�i Board of Health, _ A49U b t 1 i !-1 MA. 9 01e,10 3`(B !CERTIFICATE Of COMPLIANCE 9 Td©ci Description of Work: 0 Individual Component(s) ❑ Complete System -4 1c The undersigned hereby certify that the Sewage Disposal System; Constructed O, Repaired (X, Upgrade Abandoned( ) by: C A GtAJ t at - x has been installed in accord a ce with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. dated Approved Design Flo, jgpd) Installer Designer: C- rt,j 16jA legs (, �i )e_ Inspector:.,- g- Date; M The issuance of this permit shall not be construed as a guarantee that the system will function as designed. -- No.f7 l 14 t ?'� U < . �j t t { E ` s COMMONWEALTH Of MASSACHUSETTS Board of Health, g/�a , MA. TT' DISPOSAI. SYSTEM C®NSTRUCTI®NTERMIT Permission is hereby granted to Construct( ) RepairoQ Upgrade Abandon( ) an individual sewage disposal system at as described in. the. application for Disposal System Construction Permit No. &-2 , dated Provided: Construction shall be completed within thr s the date of this permit. All local conditions must be met. Form 1255 Rev. 5/96 A.M.SulkinCo. Chadeslown,MA Date f0 ' '` ' /;:Woard of Health