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HomeMy WebLinkAboutApp-Permit-ComplianceNo: �Q�� - �2- po�2�3 FEEZ�k/: S W .� - COM[M COMMONWEALTH OF MASS C1IUSETTf Board of Health, VAMOLrn+ , MA. l/ /r APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application fora Permit to Construct( ) Repair1A Upgrade( ) Abandon( ) - 0 Complete • System AIndividual Components Location 356 5WI-04 4YEi lJE Owner's Name Map/Parcel# 6,912-30 Address 36-6- SAJi )Af &Jy-r Lot# S Telephone# x0oa -my- Installer's Name 4,e. aAj57'p i167&7 J /46, Designer's Name B45s , J,W ��„dffbFfA'. Address /S DlANOaS AN Mllri,QN41/5, M. OZ�s(O Address P-3 //�p3 1wA/IS x4n6ell Telephone# Telephone# Sob- -369,­-yo Vy Type of Building %;�tDE1VfA2 Lot Size /8, SOa _ sq. ft. Dwelling- No. of Bedrooms 3 BED tawj Garbage grinder ( ) Other - Type of Building N14 No. of persons Showers (' ), Cafeteria Other Fixtures Design Flow (min. required) '33� gpd Calculated design flow Design flow provided -3 gpd Plan:Date fVNE 13TIi, 20/8 Number of sheets _ Revision Date Title 354 gTit7y4 AVEAVe $. , MMgA9{f� 44 - Description 'Description of Soil(s). Soil Evaluator Form No. Name of Soil Evaluator T PA S f4e_GCA7i Date of Evaluation 6-13-11? DESCRIPTION OF REPAIRS OR ALTERATIONS /N5rA'GL 0 t irW# SOO QUfi 04 jZ?fQf 4#4M&_4P1 wU %X6' . INSZfU NEW b -&X N/07f . P1?IA16- X _ EX1slN6 jWTrcc Mqt_ AWO Nth/ fte2_D The undersign grees installthe ab a bed Individual Sewage Disposal System in accordance with the provisions. of TITLE 5 and;. further agrees not t operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date _^ 4 ,= Y1 y No. C-1�tl�3Z 00 COMMONWEALTH OF MASSACHUS ETT ,1 EE Board of Health, MA. OAC - CE RTIFICATE K.CERTIFICATE OF COMPLIANCE ° �(4tq Description. of Work: �41ndividual Component(s,). O Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed O; Repaired X), Upgraded ( ), Abandoned ( ). by: G.G. Got,+STavt-oc7N ,..al=< at 3SG SKATvn/ fi✓EMti has been installed i accord `ce�with the provisions of 10 CMR 15.00 (Title 5) and the approved design plans/as-built plans, relating to. application No. �- dated. Approved Des' n ow .330 (gpd) r Installer Designer: BOSS �rd,EA E�V/�.IE IZrrtlFa Inspector: i� +alis "MC /� Date: '�-1-7 The issuance of this permit shall not be construed as a guarantee that the system. will function as designed.. No. � iti C"' 1 �?� / C.. C •.r6NS"T_R_()C- lwj FEE 6--d 0 COMMONWEALTH Of MASSACHUSETTS Ckl-23q_Z�Y Board of Health, )! %yi©un+ , MA. DISPOSAL SYSTEM[ ICONSTRUCTION PERMIIT Permission is hereby gran ted to Construct( ) RepairX) Upgrade( ) Abandon( ) an individual sewage disposal system at 3 3 6 SrA7a�/ A r f S. yet /irrt oc as described in the application for Disposal System Construction Permit No. '; dated Provided: Construction shall be •completed within. of the date of this perm . } 1 local conditions must be met. Form 1255 Rev. 5/96 A.M.Sulkln Co. Chadestown,MA Date / l Pinard of Health r