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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 6e maOzzl i�,� � Y-- C01 � � C- � �-L00 COMMONWEALTH Of MASSACHUSETTS X9 60 (, RECEIVED ✓ ��`�% Board of Health, Y(3 -r 1VIA. A L TION FOR L DISPOS SYSTEM CONSTRUCTION PER f, , - 6 *1018 Application for a Permit to Construct( ) Repair{vYUpgrade( ) Abandon( - ❑ Complete System ❑ zndivid EPT Location C Owner's Name Ari 1 e� hc. Oe�ci r'©Z Map/Parcel# O Address a M Lot# ZS' Telephone# Installer's Name Si,8 EXe0. 4loY\ Designer's Name 'GoussV-- r Address .--Address 1 aSc r o c -} O ow I 1 L3 E• .� G� n Telephone# O Telephone# 3e q O - Type of Building Q�$� Ct��►la..i Lot Size 1,'l SG sq. ft. Dwelling- No. of Bedrooms Z Garbage grinder { Other -Type of Building No. of persons Showers O, Cafeteria Other Fixtures Design Flow (min, required) 22 O gpd Calculated design flow Design flow provided 3 30 gpd Plan: Date 9-13- Number of sheets I Revision Date Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of DESCRIPTION OF REPAIRS 09AUERATIONS D 13 Oft - OO The undersigned agrees to install the above described Individual SewageDisposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliduce has been issued by the Board of Health. Signed fi Date T L a - 3o s0 le-,krA No. OZ -� e+ FEE_ COMMONWEALTH OF MASSACHUSETTS i M � Board of Health, -�06 on Q, � �. , MA. CERTIFICATE OF COMPLIANCE \0 Description of Work: U4dividual Component(s) 0 Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (v)o;*Upgraded ( ), Abandoned at�i� dR Q 6 has been installed in accordancq with the provisions of 3 0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. Clof dated JJZ Approved Design Flow (gpd) Installer. a:' a Designer: s -i- 5 - Inspector: Date; The issuance of this permit, shall not be -construed as a guarantee that the' will function as designed. I ' - COMMONWEALTH OF MASSACHUSETTS Board of Health,T��£.1 , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT - FSE 44 -e Permission is hereby granted to; Construct( ) Repair( " Upgrade ( ) Abandon ( ) an individual;, sewage disposal system at a r i� as described in the application for Disposal System Construction Permit No. dated ` - % ` Provided: Construction shall be completed within t�tJJrreee the date of this perm't. All local conditions must be met. Form 1255 Rev. 5/9d A.M. Sulkin Co. Chadeslown, MA Date oard of Health %/"e9 i. sY�• > n.d.�si .a• ,b1i 1' / it /O',Y _/ IAD,e, rOe 4 ,r f i� • I ^f'/l.A�d� %i <r,--` I'h./` /%ijO 1��� L. 1' i / '1