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HomeMy WebLinkAboutApp-Permit-ComplianceNo: — t I Tfe / I- 3-'V 7 ,-fs—� k�L 00 COMMONWEALTH OF MASS&NE Boardof Health, �Y_t ��� MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Pet -;nit to .Construct( ) Repair( .) Upgradeel"AbandonO V, Complete System ❑ Individual Components Location , / 1. f �� � Owner's Name- Map/Parcel# :, 7 10 Address Lot# Telephone# Installer's Name of 1.15211Designer's Name Address S ! _ d Address5���✓ Ar Telephone# - v Telephone# q i '7 s• % 60 Type of Building _ Lot Size Y sq. ft Dwelling- No. of Bedrooms Garbage grinder Other -Type of Building No. of persons Showers (' ), Cafeteria Other Fixtures Design Flow (min. required) 3 3J gpd Calculated design flow Design flow provided l/S gpd Plant` Date 2-9-12 Number of sheets _ I Revision Date Title Description ofSoil (s)��'- Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS � . 6 P 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 to not to lace the tem in operation until a Certificate of Coompliahce has been issued by the Board of Health. Sign ed%%i Date Inspections FEE J L7 V® _ - COMMONWEALTIT Of MASSAC14USETTS CA -*,7 3 Board of Health, Y UTW , M.A. CERTIFI ATE OF COMPLLAN'CE Description. of Work: ❑ Individual Components) Complete System The undersigned hereby certify yt th�Rgee Di oraI'S ystem; Constructed( ), Repaired ( }, Upgradedbandoned { ). by � x , at has been installed i Icor ance with the roe' ' ids of L0 CMR :15.00 (Title 5) and th,�.a roved design plans/as-built plans relating to application No. Z, dated _ Approved Design Flow-;J'-(gPd) Installer o Designer: ll ► A Inspector: c Date: The issuance of this;permit shall not be construed as a guarantee that the system will function as designed. No.ie J C,S�G COMMONWEALTH Of MASSACHUSETTS Board of Health, DISPOSAL SYSTEM CONSTRUCTION YE MIT FEE 4 703 � Permission is hereby granted to; Construct(V)"Repair( ) Upgrade Abandon ( ) an indhidual sewage disposal. system at i _ jt / as described in the application. for Disposal System Construction .Permit No,% � 52- 1 dated i ar) o Provided: Construction shall be completed withGi�n years of the date of thsp� All local conditions must be met: Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown,MA Date? Board of Health rte'