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HomeMy WebLinkAboutApp-Permit-ComplianceNo. :J��� _,40"r FEE 6 o4,D C. I q _(�� ® COMMONWEALTH Of MASSACHUSETTS Oci�l5 Z � _ �� 1 `, Board of Health, 'I ��Co ORA , MA. APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT qQ Application for Permit to Construct( ) Repair( ) UpgradeV-Abandon( ') U Complete System ❑ Individual Components location(D 5 4 -C, _' RC0 ,SP, �Z Owner's Name be r`T KoC, ap/Parcel# / e� Address (0 A f+ v- o)V &,P_ %11Q,VMOJAd t# �0 � Telephone# Ij istaller's Name 0 �. T � , O U `- Cj_� � Designer's Name RI -01 C o +� e S 1,3 ....dress ,� rJIS � J3 Si HAp�➢iL`1 ��� Address .0�&� Telephone# f� — [� Telephone#' S Type of Building Lot Size Lo sq. ft. Dwelling - No. of Bedrooms Garbage grinder { Other -Type of Building No. of persons Showers O, Cafeteria te Other Fixtures Design Flow (min. re uired) c;Q © gpd Calculated design flow o�a. C5 Design flow provided gpd Plan: Date Number of sheets_ Revision Date Title pp p _p 1.1 Description of Soil(s) A J ra�� AZO — l—®�r/�\i+t1� c AC>r tZO" — M-2C.�[_� SAncY Soil Evaluator Form No. Name of.Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS :Z:N,S r411 1.5 00 QrpL ZooNV, r U- 13cs, '-A,l3) j c' e) 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 It th Awn in operation until a Certificate of Co pliance has been issued by the Board of Health. Signed Z, Date i I ci i P4 FE 4� if COMMONWEALTH OF MASSACHUSETTS, - Board SSACHUSETTS,-Board of Health, M O i i , IVL4. 61RTIFICATE Of COMPLIANCE Description of Works 0 Individual Component(s) Qr6mplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (C„)' Abandoned ( ) has been installed in accordar,Lce with the provisions of 310 CMR 1.5.00 (Title 5) and the roved design plans/as-built plans relating to application No. �" ''", dated./-. Approved Design Flow (g_pd)Cy / `�r Installer �2 r '�"' � ,'��.3 .. s>zC/ ✓'`� - ,. `1 r � _.- Designer: 4-f r trr,;n1Y_�e Inspector:--- — Date; i The issuance of this permit shall not be construed as a.guarantee that the system will function as designed. No. hf) l- DC irl ko(0 i e � Doe-- FEE COMMONWEALTH C NI Board of Health, �1s� , MA. DISPOSAL SYSTEM CONSTRUCTION- PERMIT Permission is hereby granted to; Construct( ) Repair( _ Upgrade(V<Abandon( ) an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. .' dated I *elj . Provided: Construction shall be completed within_tl rs of the date of this permit. All local conditions must be met:. Form 1 55 Rev. 5/96 A.M..//SuulkinGo. Chadestown,MA Date ' Board of Health