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HomeMy WebLinkAboutApp-Permit-ComplianceNo. 609 -W46 -33f8 pq - COMMONWEALTH Of MASSACHUSETTS Board of Health .�'� � I ` MA. D© FEE -�- &430 APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑ Complete System Zi1ndividual Components Location 0 LZ 0*4 LAI) V Owner's Name Map/Parcel# Address 1p -- �Cv�� Lot#Telephone# -331 f Seo 5— Installer's Name '� Designer's Name p, Address ci �Uv • Address ✓t° Telephone# Telephone# 5— —171 Type of Building ��; . o ►�. Lot Size /., . PGS sq. ft. Dwelling - No. of Bedrooms Garbage grinder Other -Type of Building No. of persons Showers ( ) , Cafeteria Other Fixtures Design Flow (min. required) &D gpd Calculated design flow 3,3 o Design flow provided gpd Plan: Date %6—/�—/, 5� Number of sheets Revision Date Title Description of Soil (s) _ Soil Evaluator Form No Name of.Soil Evaluator Date of Evaluation 153 • • •W.11801 • ! The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further ato z}ot to place a st m, operation until Certificate of Compliance has been issued by the Board of Health. ees. Signed Date 6 / 5-i Oe� Inspections i No. FEE COMMONWEALTH OF MASSACHUSETTS `S {t�iA- Board of Health, yijj'�-M 0 MA. CERTIFICATE Of COMPLIANCE Description of Work: individual Components) ❑Complete System. The undersigned hereby certify that the Sewage Disposal System; Constructed O., Repaired (Upgraded ( ), Abandoned ( )` by: at has been installed application No. _ Installer with tiiovisions of0 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to dated e x �� _�. Approved Design Flow 5,?,e-s"'(gpd) Designer: # P; e,�)6 10 C--C-j (14& Inspector:Of ' the Date: 'I The issuance of this permit shall not be construed as a guarV ee that ,system will function as designed. IO' COMMONWEALTH Of MASSACHUSETTS Board of Health, �(}}' , MA. DISPOSAL SYSTEM CONSTRUCTION. HERMIT FEE` - Permission is hereby granted to; Construct( ) Repairvf Upgrade( ) -Abandon ( ) an indh idual sewage disposal system at Disposal System Construction Permit Na dated as described in the application for Provided: Construction shall be completed within three years of the date of this pe in't, All local conditions must be met. Form 1255. Rev. 5/96 A.M. Sulkin Co. Chadeslown, Ma Dat t V foard of Health t'�