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HomeMy WebLinkAboutApp-Permit-Compliance��•� ; - , . ' � ; , '�'�,�. , � ' , _ _. __, , - - _ <- ;�., o ; . \ , � , : �� `� � , , � V � •� � � � � � � � � � , '1 1 :"� �, � " `a' � ' ;`�, ,�, ,, • , , , ,��w , ' � � a ^, � f �� � � •� � , � ,�y 1 ♦ � rn � � : � � 1 p � � • i/� � y 1 � � ± � � 1 � � i � � � p � � Q�1 ^I � � � 'a A �o : -o ... :� � �� � �°�' �aao '� : � � o � . e � � � � b � o, o . : • � � -� � � 4 • � `/ �� � e R �v' � �� �„� w 6 � � � R �� � � ♦ : .� 3 . , � � � o � . , � . � � � � � y � A\'�i � � C , � ~ V �� � � � • `Rs' :-1 •y d ! � y � � � v,�'` p � � � . � y U� � � '` : �" � a; cd � a� : : '�' H � � U � ' � � � T ¢ ` � � � � : � v � � � v �y . o�, � a p O O» nt !�q � eQ � x [�, °' �I ,� : ' � � � � A� :°`y �-, � . o � a�i t�,o o : � � � �^ q ' : � �, _ . . : O 8 `�, .� ,� � ; V t3 � .c °� �° � u y � � � .r '� b � ; � � .� � ,� � . � V L.� "y,' a � .�i . �y, ,°,�° �+ . � � t � � � � i O "s". 'Cy � � : 3 '. � o � �, o 0 � � Z u ( o �� ,� o .. � � � � v � � � .� � � , ,� 6� � ""p„ � m C� � � z caH .n� � ,� � Sa €° � : � s � R 1 � FEE ✓1Wx''W",`4®N®Nxur A LTA ®r NL>4SS4C11USFTTS � �'�S� y`% Board of Health, _ YA:f OUT44 , AIA. /> x• f � i �/ 1 APPLICATION FOR DISPOSAL SYSTEM[ CONSTRUCTIO:1d,vidal 'MIT LLocadon Permit to Construct( Repair( Upgrade Abandon( - ❑ Complete System Components Owner's Name Map/Parcel# Z6103 Address Lot# Telephone# Installer's Name i Designer's Name Address /I i XA 11-r G 4 S" , Address Telephone# ,f. © Telephone# 77S Type of Building r� Lot Size 14 -,0—' �ft. If Dwelling - No. of Bedrooms S Garbage grinder ( ) Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) gpd Calculated design flow Design flow provided gpd Plan: Date 41 ' f-" /,? Number of sheets Z Revision Date ,9* Title Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator 0 ate of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS . J The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to no IaFe a 2nino ration until a Certificate of Compliance has been issued by the Board of Health. Signed Date's 2'`1 n Inspections No. COMMONWEALT14 Of MASSACHUSETTS FFE Board of Health, , CERTIFICATE Of COMPLIANCE Description of Work: individualComponent(s) ❑ Complete System The undersigned hereby rtify that Sewageispg�al System;ons tC�d ( $&paired ( ),Upgraded (�'f Abandoned ( ) 11 ,�/ 1 _ ! by: at has been installlix� acpr� ance with the pro_vis ns. gfTP CMR 15.00 (Title 5) an die xAproved design plans/as-built plans relating to application No. // % dated / / . Approved Design Flow c0 C% (gpd) Installer,� f " Designer: �L Inspector: L','-�c.�. Date: The issuance of this permit shall not be construed as a guarantee at the system will function as designed. y No./%FEE S! COMMONWEALTH Of MASSACHUSETTS., P- Board of Health, `g4M007-f� L ... DISPOSAL SYSTEM[ CONSTRUCTION PERMIT " Permission is hereby ygt ed t ;. Construct( pair( ) Upgrade(% Abandon( ) an nd adual sewage disposal system at'^re astdescnbe in the application for Disposal System Construction Permit No. / a / , dated Provided: Construction shall be completed within three of the date of this permic --All local conditions must be met. Form 1255 Rev. 5/96 M. Sulkin Co. Chadestown, MA Date Board of Health