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HomeMy WebLinkAboutBHDC-24-165oS W rb •a n� Q� o n� G N y n H v Q w r� VS r C� n � � � n A � n � o O z S � H o � NoS�k�C 214 •1f - t FEE COMMONVVEAM OF MASSACHUSETTS Alt Board of Health, T _ � °l t'): MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrad&�, ) Abandon( ) - Q'I'llomplete System O Individual Components Location Map/Parcel# Lot# Installer's Name r Address �D Telephone# 17; Owner's Name-1 1bi �r �-. r-, Address Telephone# " Designer's Name i Address Telephone# �( Type of Building Lot Size "� r i l sq. ft. Dwelling - No, of Bedrooms ne _ Garbage grinder Other - T of Building ?.S Type g G� ' No. of persons_ Showers ), Cafeteria (LY Other Fixtures _ J T t t n I,` � } � � ,� Design Flow (min. required) 4�� � gpd Calculated des �n flow .�`� Design)flow provided_ �L�/ ? gpd Plan: Date Number of sheers Revision Date r Title --- C _ -Y- iL 1 -� ` . Description of Soil(s) II Soil Evaluator Form No. Name of Soil Evaluator t Yr; ,r Y 1. Date of Evaluation - DESCRIPTION OF REPAIRS OR ALTERATIONS , (a ( ti m�- The undersigned agrees to install the abpve described Individual Sewage Disposal System in accordance with the provisions of TT11E 5 and further agrees to not to place the liystoth in operation until a Certificate of Compliance has been issued by the Board of Health. Signed ! Date Inspections No. % � � ' `"S' FEE, COMMONWEALTIT OF MASSACHUSETTS Board of Health, 7r f ~i >y ;�'�,=� q 1-15 CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) 'gComplete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded,,��), Abandoned ( ) by: athas 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. 7LZ 1 dated - Approved Design Flow r (gpd) Installer Designer: 1'^<-S q Inspector: Date: r L / _ The issuance of this permit shall not be cAnstrued as a guarantee tbat the system will function as designed. No. -1) - ,i _ 2� It '� tPt> FEE COMMONWEALTH Of MASSACHUSETTS Board of Health, f _ _ � Lei 111A, DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( ) Upgrade Abandon( ) an individual sewage disposal system at >(.., fl� t�\ . - ' (1 as described in the application for Disposal System Construction Permit No.-21-� I21Z , dated �'1 Provided: Construction shall be completed within three-vem;& of the date of this permit. All local conditions must be met. Forth 1255 Rev. 5M AM. Sullen Co. Che,kslmr MA Date Board of Health Im of A W N r+ r. 3 r► a W 1 m � d CL N c tA N �J C4 * Z m v T � v _ CL O o 3 / 1 _ — cr m Ol 3 O. N 4i r O � N G� 0 Ln m (� .N► N =r m u > OCL v3i y 7 6Zi m m c 3 Q LA N 00 N CLio m rw a r� c g CL m CL cl) v n N a 3 a m = y (� m m 3 LAy X S x C S m = O O x x m O m � N ,. 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