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HomeMy WebLinkAboutApp-Permit-ComplianceNo.g I -I �OZ9 /���y�( FEE _<r;� MASSACHUSETTS -7 COMMONWEALTH Of Board of Health, �_g{L(�1l�13"L , MA ' `"' ':4_�qI3 APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTIP' MIT Application for a Permit to Construct( ) Repair('j�) O O UpgradeAbandon- ❑ Complete System:didual Components ff�� 1P - Location C ,-_eu Q Owner's Name /G+ !.3 Map/Parcel# 16 Address Lot# Telephone# Installer's Name 2r�?6 Designer's Name Address Address Telephone# -�� _ / Telephone# Type of Building Lot Size sq. ft. Dwelling - No. of Bedrooms Garbage grinder ( ) Other -Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description ofSoil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONSX7 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a es t of to ace e s m in operation until a Certificate qk Compliancbeen issued by the Board of Health. Signed.12 Date Inspections COMMONWEALTH OF MASSACIIUSETTSj�,,, f �`t ; M ON IDA MA. Beard o Health, �-_� �, , ClET)TIFIC ATF ©ip MM THANTCE FEE t ) cn v r" ,. -e i Description of Work: 4261ndividual Component(s) ❑ Complete System �J .. The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (' ), Upgraded ( ), Abandoned( ) by C at has been installed in _accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. .F' !- dated- f ';r 0 `?''' . Approved Design Flow (gpd) s •.. Installer t r i l:'- i -(; , . �' _. Designer: "' Inspector: ' �1 r ,1%r,tf Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. l . .. '1..OMMONWlCI7CLT14 OF MASSA'1 14USETitS Board of HeeaTlth, A Mt , MA. DISPOSAL SYSTEM CONSTRUCTION. PERMIT FEE—,, Permission is hereby granted to; Construct( ) Repair(�,i) Upgrade( ) Abandon( ) an individual sewage disposal system at fr w x as described in the application for Disposal System Construction Permit No ' !' dated Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. r Form 1255 Re¢ 5/96 A.M. Sulkin Co. Chadeslown,MA Date •'`7;,`Board Of Health n r `_✓