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HomeMy WebLinkAboutBHDC-24-97Y-3 rt m x rb z v' ` O rrtt �n nq a. 0 rr C �R GN � 0 5 i i 0 y CL y r y y { Ob V. z rt m z Y n• 1_ v � -- H 6 0 j v� H O S. a. No. LiC17 R COMMONWEALTH OF MASSACHUSETTS Board r f Health, t Nm, APPLICATION FOR DISP0SA SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(,,(`Abandon( ) - J Complete System O Individual Components Location S C C,^ Map/Parcel# Lot# 1� Installer's Name R'J'q, Address Telephone# Type of Building 'Re"A 1qA A � t Dwelling - No. of Bedrooms 3 Other -Type of Building Other Fixtures Owner's Name ' � - >�.lL Address Telephone# Designer's Name�� Address K� Telephone#�� Lot Size 1. 7QQ sq. ft. Garbage grinder ( ) No, of persons Showers ( ), Cafeteria { ) D�sign Flow (min. required) gpd Calculated design flow.•__ 5 Design flow pro-6ded , e- gpd Plan: Date T��l��`-1 Number ofshee.ts Revision Date Title Description of Soil (s) _ Soil Evaluator Form No. Name of Soil Evaluator � et "6 E Date of Evaluation DESCRIPTION OF REPAIRS OR)ITERATIONS C > > 4 t - 1 (5I ci C'C�1�0.1\ �}� I C �C Grl l �1 f (7 Z(r) rokl n,r\ t or✓fin 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 lase thq system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date �,. Inspections No. COMMONWEALTH OF MASSACHUSETTS Board of Health, I . I , b �_ MA. CERTIFICATI: OF COMPLIANCE Description of Work: 0 Individual Component(s) 4complete System The undersigned hereby certify that the Sewage Disposal System; Constructed { ), Repaired ( ), Upgraded N, Abandoned ( ) by: at has been installed in accordance with the pr psi s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. r/ 10` dated L Approved Design Flow 3y� _(gpd) Installer Designer: IP _ Inspector: _tLn t _ Date: u Jl The issuance of this permit shall not be construed as a guarantee that the system will function as designed. No. \ �l�r Z�.�1-7 FEE COMMONVITAMI OF MASSACITUSETTS Board of Health, Qwta \�V 1 MA DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(` N) Repair( ) Upgrade ) Abandon ( ) an individual sewage disposal system at 'S- rrct'x,(\ Q,t(lckk l 2t as described in the application for Disposal System Construction Permit No. - 'l dated 61",41 S Provided: Construction shall be completed within 4+ ee-remj of the date of this ermiE. All local cottektioa&xrj sj 14 met. Farm 1255 Aev.5N6 A.M. Sulkin Co. CharWMA MA DateId ,— Board of Health Q1 Ul A w N F+ z �.D .A -� n >a, 3 � W do 41 � * A W c � W � 3 pr CL cr 'V A C y O lJ m cm CL 3 00 i m tb D � a m C_— CL lunl C�r� d li�l r T N��1}fb v m d S 1 m Z w R rA MAI fD D Q Q e� N i m ,-Z Ul CD CD co 0CD rt a in. w �^ n CCDCD O m a� o 0 rt ro H G1 n m CL V fo 0 0 o O fD cr fD n O o a G1 to -� C � ro CL m o SD 5 n rt � (D ro fD S 0 fCD O z�"nmEl u19 o' o �7 y w C CD G rn o fp r. Do � =. 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