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HomeMy WebLinkAboutApp-Permit-ComplianceNo. D '� �_I"`1 / V a�Z--�i' ®�2- 1 13, FEE S J . CrO COMMONWEALTH OF MASSACHUSETTS c qB( Board of Health,MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI©N PERM, IT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - I] Complete System El Individual Components Location +-{'I (3aVA Owner's Name ^PkkcRL.LTAre Ae-t'�A"vg 't'2.V2; Map/Parcel# 6.;t 7 .S Address 16ci PogC) Lot1f Telephone# Installer's Name TMv`C-rro!aq,k cov(s-r>_vcTro-f Designer's Name ot�ho'W�SR�L.P'•lk rNL ���anS Address Zr✓ sr',.�i.t4622 t_rf, W.'UN't-oao WTO Address qcc, rMrTit Sr. 1�.2C'J t^O2af Gf(. R'C d2i�4i Telephone# soS-- 922- 35K1 Telephone# Type of Building Dwelling - No. of Bedrooms. Other - Type of Building _ Other Fixtures Design Flow (min. required) Plan: Date Title Description of Soils) _ Soil Evaluator Form No S 7r9rzoom 5-5-0. gpd Calculated design flow Number of sheets Name of Soil Evaluator DESCRIPTION OF REPAIRS ORALTERATIONS Lot Size sq. ft. r ,(arbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design flow provided Y.S"O Revision Date Date of Evaluation SCP'rrc. 5V 5-, r.A1 (ZrZ0..hc.fZA42+rt'- gpd The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrgeg te.,ngt t� place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed (2V. �i All— l p Q Date 1 Imo'^ t 4s' 15 Inspections �"- r p� 1 �5 L' p -S .� (.N - pe^ j2 -- 7 1 No °?(i AV) t``� �s„.;w "a .ni' eg FEE � ;..:d�'3 .COMMONWEALTH.. 4/ C®MIM ON LTR ®F MASSACHUSETTS' ." ry t g 13 I , Board of Health, MA: CERTIFICATE OF COMPLIANCE ; ,��--==-- Description of Work: O Individual Component(s) ❑ Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (4, Upgraded ' Abandoned( ) by: 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 i`c° �'"` Oma'. Approved Design Flow 5,5_0 (gpd) Installer - VEL . m; o -r va rra r"rras s R-ti,e v r" t..ot1kV`€rFt VIIItnx"�, k.„�t^..x ! p� P :; ,: Llf':• Designer: Inspector: @""'" Date: d a- j The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. �°(. )'i `..� "� 7-S..17 'i :ilC^ � �U� fd .� FEE `')'*Y) 00 COMMONWEALTH Of MASSACHUSETTS ch -,4v Board of Health, 3��'b-' C;i.ltF"" MA. DISPOSAL SYSTEM CONSTRUCTI®N PERMIT Permission is hereby granted to; Construct( ) Repair(%) Upgrade( J Abandon( ) an individual sewage disposal system at L4-? Disposal System Construction Permit No. "E ' 27 , dated as described in the application for Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met. ' � Form 1255 Rev. 5/96 A.M. Sulkin Co. Clek9mm, MA Date Z, +'.'+K✓e'`, Board Of Health 7 -