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HomeMy WebLinkAboutDisposal System Applicaiton,Documents1. I Y rL O r Z rr o KA z \ n N G I 1 1 V V ` � V > 3' V i a n N C—j /T ro r4 O n � C�1 H 7_ No. ic • 2 3 ' 1�� 1 2-3 L1 FEE ` COMMONWEALTH OF MASSACHUSETTS Nc Q kAo"Se, Board r f Health, Goi �.���� MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construe( ) Repair(_ Upgrade( ) Abandon,, ) - ❑ Complete System O Individual Components Location GUf%ro Owner's Name Map/Parcel# -12 Z7 Address Lot# Telephone# - Installer's Name .Ysrs�i%/ Designer's Name 2 , Z-W-- Address Address Telephone# ,� r].�-_ �— Tele hone# 2 Type of Building __' Dwelling - No. of Bedrooms Other - Tvpe of Building _ Other Fixttlres Design Plow (min. required)O_ _ gpd Calculated design flow Plan Date Number of sheets Title Description ofSoil (s) Soil Evaluator Form No. Name of Soil Evaluator _ Lot Size ZL_'CZ:R sq. ft. Garbage grinder { ) No. of persons Showers 1, ), Cafeteria { ) Design flow prodded 3 ZZ gpd Re%ision Date Date of Evaluation DESCRIPTION OF REPAIRS ORAITERATIONS ►.4-r SIN (.�� ? '.�� 17 .0 - The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to nos -to -place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date e Inspections Nu• , 23 z?.o_Z ��-�� COMMONWEALTIT OF . IASSACIJUSETT 6.1`� Board of Health, ,2_:-_ .� t-. �ylq FEE _ i�k— CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) complete System ul The undersigned hereby certify that the Sewage Disposal/System; Constructed ( ), Repaired /,upgraded ( ), Abandoned ( ) has been installed in accordance with the pro isi s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. I dated Approved Design Flow 3 1L(gpd) Installer ._t&aj*t�j �i0n'1 � � _.. Designer- %�:A ._ Inspector: t ,0 -- Dater W 11,� A `T— The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. ...V ✓ 2-7—OZ, COMMONWEALTH OF MASSACHUSETS Board of Health, _ %r. s� ,t l ALq. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE Q Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at _ - f� a ', = as described in the application for Disposal System Construction Permit No. _ dated Provided: Construction shall be completed within three years of the date of this_ All local conditions must be met. Form1255 Rev 5/96 A.M SulkinCo Crude awn, MA Date Board of Health ' % Qf cn A W N r Gy ti, n co di 11 C _ d � 3 a c- a c T i p m c � T On m 0CD Ol O N 1 a ro � I a } 1 4A � N 01 3 a N O7 O' T = eo o 4 v q Gi -f ,A � _ r �ro n C tD m w �* .T� 1 N m CO 0 7 .► O N va N 'D N T N Q. 0 T 3 a s v O N a ro 7 O N Lei m Q 47 0 ro dc m � Pf tD n 7 CL m n e t; Q' 1e 3 Q. s f9 13 O an O C 0 O to = O ro ro 3 7 OJ 61 N K O .y. W N h+ 3 � n (D_ � 3 V1ul .t O O N 7 O_ m O m = v o 01 ro � ro ro T Z d 1 n{L cr Q, rr -�o C tU n ro co 0! CO ro v_ M O m cn H f�D L C 3 O se 0 o c Er d r P. 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