HomeMy WebLinkAboutBHDC-24-109C
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FEE.
COMMONWFAUH OF MASSACRUSETTS
Board of Health, _ �_ _ _ , M,q,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application fora Permit to Construct(/Repair( ) Upgrade( ) Abandon( j - ❑ Complete System 0Individual Components
Location
Map/Parcel#
Lot#
Iustal:er's Name
v r
Address;
Telephone# _ �l
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
Other Fixtures
Design Flow (min. required)
Plan: Date
Title
Description of Soil (s) _
Soil Evaluator Form No.
Owner's Name
Address v�� 61 ®o k A
Telephone# � Q,g-,� q- 055 G
Designer's Name
Address
Telephone#
gpd Calculated design flow
Number of sheets
DESCRIPTION OF REPAIRS OR ALTERATIONS
Name of Soil Evaluator
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers( ), Cafeteria ( )
Design flow provided
Revision Date
Date of Evaluation
gpd
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 CpmpliAnce has been issued by the Board of Health.
Signed Date V
Inspections
COMMONWEALTH OF MASSACHUSETTS FEE
Board of Health, ` (N MA.
CERTIFICAT 50F COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( wired ( ), Upgraded ( ), Abandoned ( )
by: Jt �Xf I'liPf EKtG.J,a
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. jr /' 11 f dated d 4/ Approved Design Flow
Installer
Designer: i -Inspector: _ _ I Date: —7 7� r/
The isiivance of this permit shall not be construed as a guarv=". Quit the system will function as designed.
No. ,1 C -�D�
FEE --
COMMONWF�4LTH OF MASSACHUSETTS
Board of Health, _ a Li t3a = t " n , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade( } Abandon( } an individual sewage disposal system
at
Disposal System Construction Permit No. 2 //:L_, dated ; C.' i_ ,
as described in the application for
Provided: Construction shall be completed within three Years of the date of thisiit. All local conditions must be met.
Form 1255 Rev. 5/% AM. Sulkln Co ChaACStwR MA Date t I Board of Health
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