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HomeMy WebLinkAboutApp-Permit-ComplianceNo: �i U I _ 1 c1 t] U 5 I (/ FEE COMMONWEALTH OF MASSACHUSETTS / �� /0 //WFol � occrd of Health, %%�iy MA. .Z.''� P�PLICATION FOP, DISPOSAL SYSTEM CONST CTION PERMIT ©K Application for a Permit to Construct( ) Repair( ) Upgrad0<_AbandonO omplete System O Individual Components Location J-�'L,. Owner's Name R WWI AW hxLm Map/Parcel# �4 Address Z x}15 1-611 L U w-- Lem, l Lot# Telephoite# s3o( - i54a . �( Installer's NameO,vdy- a1Ad tk-tk&kJ— Designer's Named J (ISG Address N .AA(ii''t 12d T_ Address &, )50 : W, ILC QZ0 3 Telephone# f Telephone# C j l5 - q _7 00 Type of Building _ _ Lot Size sq. £t: Dwelling - No. of Bedrooms Garbage grinder Otlier-Type of Building No. of persons Showers ( ), Cafeteria Other Fixtures Design Flow (min. required) gpd Calculated design :flow Design flow provided 13o gpd 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 v The: undersigned -agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and; further agr s to not thI e the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ��1�'Y1�j Date # Inspection.,;.. C26C i,CV o u a Description -of Work: The undersigned her by II II, CI `) l f at Yi da ;' has been installed i application No. Installer (_6r"t _ at 4Ah k INnVIK '- V5 (Cc- COMMONWEALTH Of MASSACHUSETTS o ' t 1-74 Board of Health y9^I_M,0(D MEI. ;' _C A V CERTIFICATE OF COMP. 1A NC 0 Individual Component(s) A- Complete System ;, r )y certify that the Sewage Disposal System; Constructed ( ); Repaired ( ), p a�e�a, Abandoned with the provisions of X10 CMR 15.00 (Title 5) and th proved; design plans/as-built plans relating o datedd� " f I . Approved Design Flow (gpd) Designer: oyi /i (' f! t! a (I(((- Inspector: " �'"'r Date: f The issuance of tWpermit shall not be construed as a guarantee that the system, will function as designed.' r No.3 bgDC-1� -p �`7 COMMONI' I.TH Of SSACHUSETTS � � -72-7, Board of Health, Y an -if MA• DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system at `'I Fl(, {' t� �^ as described in the application for Disposal System Construction Permit N�!! 7��, dated .' Provided: Construction shall be completed withixiA r Zhe date of this, permit. All local conditions must be met. Form 1255 Re . 5/96: A.M. Sulk'n Go. Cha stown,MA Date/ --4- / Board of Health i�x-:n At 7_1-