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HomeMy WebLinkAboutApp-Permit-Compliancea No. 600 � I FEE •65—DO Ord 7/ COMMONWEALTH OF MASSACHUSETTS /?% Board (f Health, &YM71 A 1 h MA. / &bT%Z - s APPLICATION x'011 DISPOSAL SYST1 M CONSTRUCTION PEI2NIIT % 9 - -C6)& Cao 7? 91 Application for a Permit to Construct( ) Repair( ) Upgrade¢y Abandon( - ❑ Complete System 4 169vidual Components Location (j A , Owner's Name Map/Parcel# 33 -120-ded Ig o Address 24 h Ily ZA5, Lot# Telephone# 9 7g, -1 994-0 6 Installer's Name Designer's Name Address ©( Address I'a Ai Telephone# -3 _(� ( Type of Building Dwelling - No. of Bedrooms. Other -Type of Building _ Other Fixtures Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design Flow (min. required) Z. LU gpd Carculated design flow Design flow provided gpd Plan: Date Number of sheets_ Revision Date ril-2...I Iq Title Description ofSoil (s) _ Soil Evaluator Form No. Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS MID Date of Evaluation The undersi ees to install the above des asped Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agte s to t lace to s st n •• flon until a Certificate of Compliance has been issued by the Board of health. Signed � Date�O � 7 �� / C.714I -1-t - ofc- No �?.�4 ( �t �, _. „i(. `J^w w°r �°FEE �t ., R COMMONWEALT OF MASSACHUSETTS � 1 � ;� 0 M Board afFlealth, t.C�'4 4 :`Y'7 ti 1 i ( p �( , tYlA. 01 `o O(�`` CUITIFICAA OF COMP AINICE Description of Work: Q.^Individual Component(s) O Complete System The andrsigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded (,,')',"Abandoncd ( ) by:' �, has been installed in accordance with the provisions of 3}0 CMR 15.00 (Tide 5) and,dr aapproved design plans/as-built plans relating to application -Non f' f a/ dated , " . r'? Approved Design Flow ^' %' �i (gpd) i Installer rt t d>t` t(� d i e ,' r � a Designer: ( k ¢r ! ° e �i 1 � u x i U"' I( J�spcctor: %au -,.e ; .��" '..4r ^'a,. F Date: Tv r7/ The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. Lf4 q tY` d 004 y^"^1 ': .R- ,-' FEE 15'5 COMMONWEALTH OF MASSACHUSETTS h`i 104 Board ofHealth, i C I (°_..l MA. DISPOSAL SYSTE CONSTRUCTION PERMIT Permissionisherebygrautedto;Construct( ) Repair( ) Upgrade(] Abandon( )an individual sewage disposal system at as described in the application for Disposal System Construction Permit No. ✓ G'" . r : r / , dated ro (a Provided: Construction shall be completed within•thre years of the date of this permit. All local conditions must be met. Farm 1111 aev. 1196 AM SWkln co. Chak$v}x,,n M4 / Date ftoard of Health C¢ ll' � j .} i N 1'gyp^ � / v `/ N ®� y^l:'.!.✓ f f )'�/ ^16 ,°