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HomeMy WebLinkAboutBHDC-24-160-N v: V y F OQ to ac °o fb kJP�1 4 t � c N f� cr S 6 C) v C'Q J C• fD y M a. v ^o 4 w r- o N �n r � 2 ' y1 2 3 N 5 � 2 � � Cn! w 1 0 1 � 3 N C� � r � n C C%1 a 1 C ❑ n V J VJ c O. o v5 � M 0 a �o 0R N �Ca� ?a < r p- � CD CD OQ r! a I� A G. �d� aQQ �"• O H x b 0 �I�VBar z � '.< — /n y O ^. fD W [D "C� tz cr r. c v, 7 a; m CD oN CD w 2L co O • w go to CD w OR y CL ° r O gn I" io MZ �- L AON CIF—/Um@91M 7� h ro a v t �o G> w n � � a n C C :t a �O'n a y w m r no tr m H fD 01 7 fl_ N N fp T K m �p � 1 ' — 0 fu 0 rp �. m m c 1 Z D Z v su a i \ I Qt i 3 U w n r9 M `-7 No. 41 (12a � FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, N t"WOV,' N �'} MA APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - © Complete System O Individual Components Location Owner's Name 14.1 g y /O Map/ Parcel# Lot# Address Telephone# ' Installer'sName21L Designer's Name -1G7 Address �j- Address 190. 30X 3 31 Telephone# -Telephone# -27'V — f — �fG� Type of Building %? , , ' y ! Dwelling - No. of Bedrooms 2 ✓i't �� �J �o/ 3,_ Other - Type of Building ' Other Fixtures Lot Size sq. ft. Garbage grinder ( ) No. of persons Showers ( ), Cafeteria ( ) Design Flow (min. required) gpd Calculated design flow _ _ _ _ Design flow provided gpd Plan: Date / r I '�_ _ Number of sheets _ Revision Date Title Description ofSoil(s) _ Soil Evaluatdr Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR AI TERATIONS f._ if/ G r,� i - .1�0, % , s �ii i n�/ /0,JAA?w 4C f I'500ge,110,1 A/-V -+'Aare It"if - if ;C) i SGt &/Ir+rJ/1a 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 Compliance has been issued by the Board of Health. Signed r--� ��^� Date Inspections COMMONWEALTH OF MASSACHUSETTS l &1 ( FEF l Board of Health, MA. CERTIFICATE 4 COMPLIANCE Description of Work: U Individual Component(s) J Complete System The undersigned hereby certify that the Sewage Disposal System-, Constructed ( ), Repaired ( ), Upgraded ( ), Abandoned ( ) -r�r�i N . / NC by: I l at ._ l�� 9--_ a .n/(2� Rd Ir.Ca./P"S V e 11✓'Gl�� .._ ... __ —__.. __—_ f has been installed in accordance with the prp,,i q is of 310 CMR 15.00 (Title 5) and the approved design plans, as -built plans relating to application No. 1 n i dated Approved Design Flow, (gpd) Installer ✓ r_v_ f Designer: '_ r �...1t� Inspector: + Date: The issuance of this permit shall not be construed as a guarantee that the system will fLILon as designed. No. COMMONW[ALTH OF MASSACHUSETTS Board of Health, V h'\A , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT FEE � � --2 Permission is hereby granted to; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system at Disposal System Construction Permit No. Y1- r dated as described in the application for Provided: Construction shall be completed within three years of the date of this permit. Alt local conditions must be met. Form 1255 Rev 5/96 A.M. Sulkm Co ChadedovaMA Date �;' Board of Health r r r r r r i i i r ®� rrl G1 9 Q. �' A � D rrl Z (A d p C% h A rr2 A O C') m F1 €i-4C m o er 0o , C A 1 N N C! r n D m m P Y s g m �xra"IZ�Z 3aa��� m iso� m so —� d08 NbNdNong 1- Q r n ;1 -0 N M = -j D O m(A T ;o0 Dmo � r �0 Q G) O m C Om m m D r (1) m = / �v r.�--0p0 Lq C -0 ry 0 O o D T () O Z C r G) 3 r•. � � o00000 - w o n p o z v�i w=p : „ o��o — 03 A 2 G Z�24 r- M m N rn= S. HEALTH DEP7 0 0 z z a ��2 +• r CD y �nrr x � � 3 - .� a (n 00ri 00000 a CD 0000000 0 000ao00 aaooa 0 aao z! s oo00000 0 00 000 o C' 000000a 0 n rtrtrtrtrtrta n CD C2 < a � a m to a �- PS w - n Op X m vow Ql