HomeMy WebLinkAboutBHDC-24-179No. eI1� -2L4 ` 01
91j i �Y `v FEE UQ
COMMONWEALTH OF MASSAC14USETTS
Board of Health, )L mwh� -'MA. F
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PER, IT CCT 0 6 2024
Application for a Permit to Construct( ) Repair( ) Upgradeg Abandon( ) -*Complete System ❑ Individ Com�sonen DEPT
Location —93 P.Owner's
Name C
Map, Parcel#
Address
Lot#
Telephone#
Installer's Name
Designer's Namex'
Address G3� S
Address. A
nz
Telephone#
Telephone#iM371
Type of Building 'P1(JM&4( Lot Size X, 7a7 sq. ft.
Dwelling - No. of Bedrooms 5 Garbage grinder( )
Other - Tvpe of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required)
Plan: Date
Title o?3 ek%644
Description of Soil (s) -1
Soil Evaluator Form No.
550 gpd Calculated design flow
Number of sheets
Name of SoiTEvaluator
II
Design flow proNided gpd
Revision Date
Date of Evaluation ?-9 ZP2y
The undersigned a install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees t lace the system in operation until a Certificate of o pliance has been issued by the Board of Health.
Signed Date
Inspections
No. ; � 9 �r L y I V6 FEE (' t
COMMONWEALTH OF MASSACHUSETTS
Board of Health, / ,y /,/ MA.
(� r' APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upg1-ade(,V Abandon( ) - *Complete System ❑ Individual Components
LOCaUOtl _�13 1. ee,j,411 1 7 �Y 1? -
Map/Parcel#
Lot#
Installer's Name �V
Address
elephone# .5gj�- L;, ,
Type of Building
Dwelling - No. of Bedrooms 5
Other - Type of Building
Other Fixtures
i. Design Flow (min. required) sue'
Plan: Date - lr' 0ZI
Title 23 66 � il, ('f floc.
DeseriptionSoil(s)
it Evaluator Form No.
gpd
Number of
DESCRIPTION OF REPAIRS OR ALTERATIONS
Owner's Name
Address o215—
Telephone#
Designer's Name
Address
1 Telephone# 5,?$— 273-
. Lt:Ch•rh�J..l
_ Lot Size �` Z sq. ft.
Garbage grinder ( )
No. of persons Showers ( ), Cafeteria ( )
Calculated design flow 55 �7- Design flow provided gpd
heets. Revision Date
Name of Soil Evaluator y%%- %/�1C.l�C� Date of Evaluation
The undersigned agrees tb install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to Rlace the system in operation until a Certificate of Cogrpliance has been issued by the Board of Health.
Signed _ Date 1�/2VL y
Inspections
No. Y ! �� FEE » '�
COMMONWEALTH OF MASSACHUSETTS
Board of Health, Ywrli LA MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Components)Complete System
The udersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ( }, Abandoned ( )
by: 1 �, o C�.
at 6/y4! IVc
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. / dated Approved Design Flow __(gpd)
Installer ��txt� � (ice 1l1 _
Designer: tV%VAWI(Vl F''L- Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. ��- 2-4 • �—)q
COMMONWEALTH OF MASSACHUSETTS
Board of Health, _ i ; i M,q
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 1. r
Permission is hereby ranted to; Construct(,(} Repair( ) Upgrade( Abandon( ) an indi,.idual sewage disposal system
at �^ ` . ��1„�,L '1YC. \/G1(y•r1.1 V1 f b4 as described in the application for
Disposal System Construction Permit No..- t / k dated /O i r
Provided: Construction shall be completed within �'�� �r tl�ree•yeat5�of the date of th�,44w it. Al[ local conditions must be met.
Form 1255 Rev 5M AA Sulkin Cc CheoWoon MA Date Board of Health -
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