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HomeMy WebLinkAboutApp-Permit-ComplianceNo. goa Vc Aq—ic4 ?A �j / 9 % % ! 1/ FEE $�- -yv COMMONWEALTH OF MASSACHUSETTSz ";Wr Board of Health, % i0 , MA. le4�� TI F DISPOSAL /SYSTEM CONSTRUCTIOA ERMIT/ 1 `A plication for a -Permit to Construct( ) Repair( ) Upgrade( ) Abandon( - ❑ Complete System Q Individual Components Location 6 5' , ( LV, Owner's Name ei/ ! Map/Parcel# �� Address Lot# Telephone# Installer's Name , �e Designer's Name Address,72 G' J Q,� Address e r 11 Telephone# 5/_;a _ 01 / Telephone#'rag p Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Z- Garbage grinder { Other - Type of Building No. of persons Showers ( ),'Cafeteria Other Fixtures Design Flow (min. required) Z Zd gpd Calculated design flow Design flow provided 7— dr Z-- gpd Plan: Date "� Number of sheets % Revision Date Title Description of Soil(s) Soil )'valuator Form No. Name of Soil Evaluator lo- af M- lelld ✓J Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS =i4 xko,� 11 ev Mr '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 system in operation until a Certificate of Compliancehasbeen issued by the Board of Health. Signed I` _ Date Inspections No. �c''s�� . ' l t) ! r FF E �2, ©O COMMONWEALTH OF MASSACHUSETTS,?. -74z - "r Board of Health, Ad...r%1& , MA. 0-7117/19 !CERTIFICATE Of COMPLIANCE Description of Work: The undersigned hei bv: at 8/ has been installed in application No. // f�`Individual Component(s) O Complete System >y certify that the Sewa�' Disposal Sygm Constructed ( ), Repaired ( )Upgraded ( ), Abandoned ( ) with the provisions of .0 CMR 15.00 (Title 5) and thre approved design plans/as-built plans relating to dated Approved Design Flow (pd) ` I a Installer - ► ! / / . _ in rr - r -w=-�-V r r Designer: --%l1e-,l Inspector: Date; r The issuance of this permit shall not be construed as a, guaran a that the system will function as designed. No. E, i i �" 1 > : ° l -(' a ( ", "� FEE . c.�`c.1 ' f COMMONWEALTH Of MASSACHUSETTS 201,3 Board of Health, )/" Md '�} , MA. DISPOSAL SYSTEM CONSTRUCTION' PERMIT Permission is hereby granted }} to;,, Construct( ) Repair'(�Upgrade ( ) Abandon( ) an indh idual sewage disposal systerb- at d !`! s� .tea, �s. �d �' s as described in the application for Disposal System Construction Permit No. dated tJ /1 Provided: Construction shall be completed within tlwee ars of t ie date of this permit. All.locaI co ditions must be met. Form 255 Rev. 5196 A.M. Sulkin Co: Cha�eslown, Mn Date -- Board of Health