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HomeMy WebLinkAboutApp-Permit-Compliancet "3Go Z- 1)4y L4,gav- FEE65 COMMONWEALTH OF MASSACHUSETTS 44[wlb ECI Board of Health, Y699 07_4 MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER 1M' 2 3 2019 HEDEPT Application for a Permit to Construct ORepair Upgrade(Abandon ❑ Complete System Aindivideal Q Location '35 ! Ara ruQ 4V Owner`s Name L is ( Sew Map/Parcel# - _ Address 3 . k4AS-rtxjts Auc W,A Lot# Telephone# Installer's Name �UFCtJ Designer's Name A Address 1:53 (:20-YL,Cr1 ST Address Telephone# _ -7 "j - -Z Telephone# Type of Building' t2 1CS 4 0 EV -1 l A -C.., Lot Size sq. £t. 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 ALTERATIONS -CN S n mac- dU E2A..) 14 77� b -116Y- c.AJ Q-64 R `SGP - The: undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions. of TITLE 5 and; further agrees to nato pla a thesystem in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date 17 No. Pa©Dc-I�r - °�Z-t�2- - I`�/ / �te1/' rEE - C1 f � !�2— COMMONWEALTH_ OF SSACI_U ETT& Board of Health, r�2./1ddt1T"F� , MA. a� CERTIFICATE OF COMPLLA?\TCE Description.of Work: XIndividual Components) ❑ Complete System The undersigned herebyc rtify that the Sewage Disposal System;. Constructed ( ), Repaired Al Upgraded( ), Abandoned ( by: C� P&" )M/gtE at U45 YAP - has been installed p'i accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application, No. l " fi . Z dated,; Approved Design Flow "'--.., (gpd) Installer L L - Designer: _f� Inspector: Date:. The issuance of this permit shall not be construed as a guar nae that the system. will function as :designed. No. 44. p L'f 1� G . ka (��'C W 1 �1ri1t--- FEE' /-�;-,2— COMMONWEALT11 Or, MASSACHUSETTS f (� Board of Health, Y OUT)f , MA. DISPOSAL SYSTEM( CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(x) Upgrade( ) Abandon( ) an individual,sewage disposal system at 3 5 A s—,� IU � F = �1� • 7 A�L as described -in the application. for Disposal System Construction Permit, No. 1 /r.�� dated Provided: Construction shall be :completed within three years of the date of this perinit:. All local conditions must be met. Jam/ f ^ Form 1255 Rev. 5196 A:M.:Sulkin Coy Ghades(oWn, MA Date'- / Board of Health� �" l./gi ..r ,.,