HomeMy WebLinkAboutBHDC-24-78No, �C
FEE 1-U. —
COMMONWfALT14 Of MASSAC14USLTTS
Board of Health, \\c/ (eiV,c A ` , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - 3Complete System ❑ Individual Components
l.ocationIC-A �e (
Owner's Name
Map 'Parcel# 5g -3
Address
Lot# 1.1�
Telephone# Got Zc1-L- 1 \ C-\
Ltstaller's Name
Designer's Name
Address Q V-t�oN�'i
Address \-Lrc
Telephone# r, 3�,ti- oo S.g
Telephone# (:50b) LM- 53\
Type of Building X rD\ G`� C-,\
Dwelling - No. of Bedrooms -L CCc5\Gr For �1
Other - Type of Building
Other Fixtures
Design Flow (min. required) 336 gpd Calculated design flow Design flow prosidedgpd
Plan: Date 51 �4s1 Zd2.L'\ Number of sheets Z Recision Date
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil
DESCRIPTION OF REPAIRS OR ALTERATIONS
\ �% &- 2 — 1 \ \ \- \ . \_ \.
No. of persons
Lot Size 1 C'\ sq. ft.
Garbage grinder( }
Showers( ), Cafeteria ( )
Date of Evaluation
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with i kj provisions of 33MSMd
further agrees to not to place the system in operation until a Certifcate f C mpliance has been issued by th e Bo ef�l" gpd,
_� �
Signed _ Date Z �'
MAY 'r01024
Inspections.— ---••-- . .._-• - -�_
<te-
No, �1� Z Lj
FEE
COMMONWLALT14 OF MASSACITUSETTS
Board r f Health, _ MA.
zl
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade(T,) Abandon( ) ® Complete System O Individual Components
Location
Map/Parcel#
Lot# t 1
Installer's Nai
Address
Telephone# ' -,-1 �� 3C \� _ (_)C) C1
Owner's Name'
Address LC 1'
Telephone#t,
Designer's Name C
Address 'IL
Telephone# j(
2S-7_ -
Type of Building 1 �C.C1� t G.\ Lot SizeVt` ;� sq. ft.
Dwelling - No. of Bedrooms L r L� f' S �. IR C V { 1 _ Garbage grinder ( )
Other - Tvpe of Building —
No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow .;min. required) gpd Calctilated design flow Design flow provided }J . gpd
Plan: Date 2 0ZL _ Number of sheets L Revision Date
Title i tP ��� �' 1'1 1-N'n �. `'i`L. 7 \" <
Descriptior.ofSoil(sj'.?-1 kill ^R `��C.c+ t ~�� \ 7'i'Pc� tC1e
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS - AL II 'k ri 1 -� ry [\1
I f r
The undersigned agrees to instatl the above described Individual Sewage Disposal System in accordance with the provisions of TTFLE 5 and
further agrees to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed „�. - Date
Inspections
- - FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, \!I r.Ii co. . ; � � MA.
CERTIFICATE OF COMPLIANC
Description of Work: ❑ Individual s Com onent r p () Cy7 Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgra Abandoned ( }
by: L P',
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.J' p S{� dated � /� a), j . Approved Design Flow, `i" (gpd)
t"1< Installer , 1
�7 Designer;," -tt. , . ,; r�j {/C i (�� Inspector: - Date: —
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.-:+C��1- C�
FEE
COMMONWEALTI4 OF MASSACIIUSETTS
�r
Board of Health, -N,1 h _ AM,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( } Repair( ) Upgrade(r) Abandon( ) an individual sewage disposal system
at r
_ as described in the application for
Disposal System Construction permit No. 1`/ O '5- dated / `'
Provided: Construction shall be completed within � t
P � the date of this it. All local conditions must be met.
Form 1255 Rev 5M AA Suikin Co CWeOm MA Date a i2, J'L Board of Health
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MAY I fit.2024
HEALTH DEPT
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This Floples floor plan is intended to represent the flog of the property and may not accurately represent the dimensions of each room or the property as a whole FI o Plan
Copyright 40 2024 Financial Business Systems, Inc. All rights reserved.
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