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HomeMy WebLinkAboutApp-Permit-Compliance(-5'Z61,4 c�'�x/ ,� syr 1�'0.: `� V �J � 5 � �/ FEE 7 � LD i- ®M[��O LTH Of MASSACHUSETTS C I lc� 8 Jq � � of Health, )�MQ yn}i , 032019 4 z SATDISPOSAL SYSTEM[ CONSTRUCTION PE Application for a Permit to .Construct( ) Repair(-) Upgradef,-�A�d bandonO - © Complete System ivid Irtli TH DEPT. Location Owner's Name t Map/Parcel# 41 lu Address 54 ar aftin Ut�Lrh Lot# Telephone# Installer's Name asy(• elf Designer'sName ! F 1 i" 1 61 V1 Address30 �5 I Address 4 o i v l Telephone#� - `�-f Telephone# 0 _ _ Type of Building _ Lot Size sq, ft. Dwelling -No. of Bedrooms _C�_ Garbage grinder:( ) Other -Type of Btulding No. of persons Showers (' ), Cafeteria ( ). Other Fixtures 5 Design Flow (min. required) c=gpd Calculated design flow Design flow provided A2 7 d Plan: Date Number of sheets _ Revision,Date Title Description of Soil('s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The un&r.signed.agrees to install the above described Individual Sewage.Disposal System in accordance with the provisions. of TITLE 5 and further agrees t lace the tem in operation until a Certificate of Co pIi has been issued by the Board of Health. Signed. Date ' Inspections _5 �toR�C No. ""' I "-% A FEE C) COMMONWEALTH OF MASSACHUSETTS Board of Health; VA9M0 1.ffl4 MA. _ CERTIFICATE Of COMPLIANCE Description of Work: �dividual Component(s) ❑ Complete System The undersigned hereby certify that the Sewa e Disposal System, Constructed ( ),Repaired ( ), Upgraded (• 'Abandoned ( ). by has been installed in accordance with the Provisiplis of AO CMR 15.00 (Title 5) and the ;appGred design plans/as-built plans relating to. application. No. tf /� dated. ' 12 ! Approved Design Flow -'l�` Installer) 4k t6"'" i 1AA LI I r!Cr Ak C.L ^uIn+ Designer: AA 6L, ��� 7titi Inspector:Date: The issuance of this permit shall not be construed as a guarante6-that thesystem. will function as designed. No. 'COMMON 'COMMONWEALTH OF MASSACHUSETTS .Board of Health, Y 60114! , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE . o Permission is here ''jby.g,(ranted to Construct( ) Repair( ) Upgrade�~'j� Abandon( ) an individualsewage disposal system 12 at r L', 'iii J t 4 i7 a . i as described in the application for/ at AM Disposal System Construction Permit No. J -" -7 ; dated - 12. % 3 Provided Construction shall be completed within ars o/f the date of thisP erm t. All IQcal �zrl Aitions must be met. Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown, MA 7Y��at 1� l !� Board_of Health / �%'