HomeMy WebLinkAboutBHDC-24-1825
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No. _�� �L � � - �� � 7 FEE
9
9/-/W
COMMONWEALTH OF MASSACHUSETTS
Board of Health, /fh?oy-f MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Constntct� ) Repair( ) Upgrade`�j Abandon( ) - Complete System O Individual Components
Location
Map/Parcel#
II Lot#
rnstaller's Name'
Address 1 /<
Telephone# 1,-77_ -
Type of Building ,/A,- --
DwFlling - No. of Bedrooms
9t15er -Type of Building
Other Fixtures
Owner's Name
Address 75/
Telephone#
Designer's Name
1 Address
Telephone# r- j'-
_ Lot Size _ ,S , _ sq. ft.
Garbage grinder( )
_ No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) Z*) gpd Calculated design flow �i�• 2- Design flow provided gpd
Plan- Date - Ua /Number of sheets ReAision Date
Title a AV1( Ails —
Description of Soil (s) N4a 71e �itG /Sl. �rti�ii
,Soil Evaluator Form No. Name of Soil Evaluator _ rf�% r/iyfr,t l Date of Evaluation
ODESCRIPTION OF REPAIRS ORAITERATIONS IFCL41 r 4-,,1k A
�/2W r'1/�.,•!r r''t .. � _ fL • � ,; .rr� �, err'
The undersigned agrets to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agree~ to not to place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
Inspections
9r
y COMMONWEALTH OF MASSAC TS l E
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ,Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ,(k), Upgraded ( ), Abandoned( )
by: Waj -1 /a.
atWT., has been installed in accordance with the projisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application
-�No. / ,) dated c Approved Design Flow ��(gpd)
le1/y0
Installer /r+L41i � �d. I _
Designer: _ : i'�;l,v.. �.; ,i 4C Inspector: -�- i, i ✓ _
---,r P ��h�. Date: —�
The issuance of this J$ermit shall not be construed as a guarantee that the system will function as designed. '
No. �A
COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE— _
Permission is hereby /g/ranted to; Construct()� Repair( ) Upgrade( 'J Abandon( ) an indi-, idual sewage disposal system
at J7 Jlllt�el 4 k`_ / � n. �i `' as described in the application for
Disposal System Construction Permit No.,t dated .
b r.7 -? 1�• j
Provided: Construction shall be completed within throe-years'ofithe date of this permit. All local conditions must be met.
Form 1255 Rev. 5/% A.M. Sulkln Co. Ndesion,MA Date � :— Board of Health
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