HomeMy WebLinkAboutBHDC-24-370
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COMMONWLALTI-I OF MASSAC14USETTS
OL [ V Board � f Health, 1L �� MA.
a
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application foi a Permit to Construct( ) Repair4/� Upgrade( ) Abandon( ) - O Complete System 5r1ndividual Components
Location
Owner's Name
Map/Parcel#
Address /
Lot# 4 L
Telephone# �9 y/ oaa �
Installer's Name r
t 1
Designer's Name
i 7
Address L�5 t i /4 Qk
Address
Te:ephone# !_
Telephone#
Type of Building., rPS�eII f �(1
Dwe!hng - No. of Bedrooms
Other - Type of Building
Other Fixtures
Design Flow (min. req fired)
Plan: Date
Tit:e
Description of Soil(s)
Soil Evaluator Form No.
gpd Caiculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
d 2Il5 ii SIPS`7C1
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder ( )
No. of'persons Showers ( ), Cafeteria ( )
Design flow provided gpd
_ Revision Date
Date of Evaluation
a ly
R The undersigned agrees tom a above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
^ further agrees to not to plaCe Af a a7ste d in operation until a Certificate of Cogtpliance has been issued by the Board of Health.
Signed / Date /J
Inspections
COMMONWEALTH OF MASSACHUSETTS FFE�r
Board of Health, , MA. --T-1 --46r�
CERTIFICATE OF COMPLIANCE
Description of Work: 0"ndividual Component(s) ❑ Complete System
The undersigned hereby certify that th Sewage Disposal System; Constructed ( }, Repaired ({;, Upgraded ( ), Abandoned ( )
by: 24 41�,
at Au i
has been inst,-i led in accordance with the provisions of 310 CMR 15,00 (Title 5) and the approved design plans/ as -built plans relating to
application No. _ `I- O V U dated -3 - / .r'`�_ Approved Design Flow _' (gpd)
Installer rfi,
Designer: -NJjA j, ✓1P _ '' ` Insp
I
The issuance of this permit shall not be construed as a
NoLI
j — 24
Date: �` t
system will function as designed.
COMMONWEALTH OF MASSACRUSETTS
,board of Health, 10 ( MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permissio is hereby granted to; Cos 2}ct{ ) Repair{ Upgrade( ) Abandon( ) art indhiclual sewage disposal system
t as described in the application for
Disposal System Construction Permit No. �/- - dated : L
Provided: Construction shall be completed within three years of the date of thisprrmit. All local conditions must be met
Form1255 Rev 51% km SulhmCc Ch#es wn,MA Date > / e) .1_ Board of Health
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