Loading...
HomeMy WebLinkAboutBHDC-25-27/ CIE)/ \ a — CID �\ ® 7 � o o �! § . 0 W w 2 f .�Jill �� rIM S E I m \ Q E�2 ] k % § (D CA 0 n 7 7 ) Gm�E0 \ ] § \ / 6 m-; D m c offƒ � / c ¥ 2 \ ƒ2k k$ z a) C Eƒk § \ $ ] = Z U f / § g --Im I k � k E _£ zr o � § n 0 CD© © _/ � \ t > % § / ® 2 CD CD CL § > $ - 2 � e c o 2 _ � ■ w cn E \ © & / w � � 2 c 7 $ \ k rr 3 3 $ \ § ■ _ ■ J 0 0 FrI 2 n 7 I§ 2 § d c � @� K § $ CD ¢ ■ 0 � ¢ n a / § ] $ � % _\ g N, 1, %3 4/36' -1s-A7 COMMONWEALTH OF MASSACHUSETTS Board r f Health, t11A. FEES APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Applit:atioii fcsr a Permit to Constt•ut.t( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System U individual Components Loca[iot[ 3� �/i� `jf b,. Or Owner's Name a rT so s�si► Map/Parcel# Address Lot# Lowsr C ex ( o,, A CO 400,(0 ., Telephone# Installer's Name LO{,./l r to [ / Pr,(- A4rr4e 4cov Designer's Name Address C �sr �q rtC� Address Telephone# S 66 7 3 113 Telephone# Type of Building Dwelling - No. of Bedrooms Other -Type of Building _ Other Fixnlres Design Flow (min. required) Plan: Date Title Description of Soil(s) Soil F.Naluator Form No. Lot Size sq. ft. Garbage grinder { ) No. of persons Showers ( ). Cafeteria ( ) gpd Calculated design flow Design flow provided Number of sheets _.. Revision Date DESCRIPTION OF REPAIRS OR ALTERATIONS Name of Soil Evaluator Date of Evaluation 330 gpd The undersigned agrees to install the above described Indi«dual Sewage Disposal SyVem in accordance with the provisions of TITLE 5 and further a revs to to lace the system in operation until a Certificate of Co tpli ice hay; been issued by the Board of He Date Si;yi:< 1 t � �.� V /,e�1 �. ) r Inspections /\ j /J - � // /j� - f-x No, t t F CtOMMONINI ALTI-I OF MASSACHUSETTS Boatd of Health, i411ua A11A. f s CERTIFICATE OF COMPLIANCE Description of Work: ❑ Individual Component(s) 0 Complete System The undersigned hereby certify that [lie Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( }. Abandoned 1 i bv: o w l iq ( A, at 3 a iz i h- j e deb Or has been installed in accordance with the )t•ovisionsyf 110 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. ,dated Approved Design Flow tJA _(gpd) Installer 1buiar %el 110L Designer: N k hispector: Date: The issuance of this permit shall not be construed as a guarantee that the system will function as designed. FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, : MA. DISPOSAL SYSTd CONISTRUCTION PERMIT OW Pet•misssion is herebylgra jnted to; Construct( ) Repair( ) Upgrade) Abandon( ) an individual sewage disposal system at S I W ('M^ b le Od 6► Vr as described in the application for Disposal System Construction Permit No. a dated V Provided: Construction shall be completed Hithin 6 of the date of this permit. All local conditions trust be met. Form t255 R 5196 A M S IK C C tee MA D ,a '� ev u m o , MR ate _ oat d of Health