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HomeMy WebLinkAboutApp-Permit-ComplianceLFUt k_,HMvEly) No. _$QNB—zo —3531 MAR 0 3 2020 20 " O U d COMMONWEALTH OF MASSIACHVSgEPT. Board /f Health, MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(t,y Abandon( - 516omplete System U Ltdividual Components Locadon1` JG:�.—� i �-•e�� �. Owner's Name Map/Parcel# t Addresse��,"G , V Lot# C:11 Telephone# L Installer's Name Designer's AddressLj -- �s / � Address Telephone# Telephone# Type of Building Dwelling -No. of Bedroc Other -Type of Building Other Fixtures No. of persons Lot Size ?'SJ sq. ft. Garbage grinder ( ) Showers ( ), Cafeteria ( ) Design Flow ^(min. required)t'J gpd Calculated design flow Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No, Name of Soil Evaluator l . 4VIoP_v=f--r- Date of Evaluation Q QD DESCRIPTION OF REPAIRS OR ALTERATIONS �i✓.�5 > C Sd'� n� Sz-,'�S_� Taw �� W -Q i7� 5 w 1 n , ly w �C7Y !�! ;• G l- 7 Q The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date c� tea_ No t":Pg ilt".... 2c)- . S ,,� i �t ...em.. FCL COMMONWEALTH OF MASSACHUSETTS � : "....r` " Board ofHeolth, cwt.^.,g MA. � r M t CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) ©,Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded Abandoned ( ) T byat has been installed in accordance with the pr visions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No, f 0- ou U dated r -d 'sr L. C%J l,,�Approved Design Flow (gpd) Installer �C. a, • `tel s:'°_'" t ..� , Designer: `9'�° a r•- ,S .4� �, r-. "s`'r,�' Inspector: ,r lata a Z, 1110. 11'll, Date: The issuance of this permit shall not be, construed as a guarantee that the system will function as designed. ° No. p_sf=- ''(.t �`', G"'w., �_� `'�.- t:w'^t"-''+.�e FCL' /.... ) COMMONWEALTH OF MASSACHUSETTS (0,35'72, Board of Health, A ' MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade(,,)' Abandon( )art individual sewage disposal system at i "' i as described in the application for Disposal System Construction Permit No. ' (' 1441 , dated Provided: Construction shall be completed within three years of the date of this permit All local conditions must be met. 1 1 l r f( f" At Form 1265 Rev. 5/96 A.M.&ulkin Orr. Chddavh MA Date (' 7t`�ft Board of Health. li