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HomeMy WebLinkAboutBHDC-24-157��`l J fT-p— lONo. FEE �J5 COMMONWEALTH OF MASSAC14USETTS Board of Health, "Ime , MA. APPLICATION FOR DISPOSAL SYSTI M CONSTRUCTION PERMIT Application ioi a Permit to Construt t( ; Repair( ) Upgrade( Abandon( ) - © Complete System ❑ Individual Components Location �,b�jj l = Owner's Name lvlap/Parcel# Address -66 Lot# 8 Telephone# Sa — 3�9 Installer's Name Designer's Name rnL. Addres Address � Telephone# Telephone# 77 Type of Building k_rV4&Wf!21 Lot size _ 341 RW sq. ft. Dwelling -No. of Bedrooms Garbage grinder ( i Other - Tvpe of Ruilding No. of persons Showers ( ), Cafeteria ( ) Other Fixtures � Design Flow (min. re aired) 7v gpd Calculated design Flow Design flow provided 9S .gpd Plan: Daaattc ?, y Number of sheets 2 Revision Date Title 7/�OSiI'� k-e' %ML 4�r� MoflaeLp Description of Soil(s) _/%W SQ/w La.) a /V It Soil E,.a:uatoi Form No. Name o, Soil Evaluator DESCRIPTION OF REPAIRS OR Al 4 AAM ) hJWgY )�- Date of Evaluation The undersigned agrees t install the above described Individual Sewage Disposal System in accordance with the provisions of TFFLE 5 and further agrees to t t la the on until a Certificate of Co pli ce has been issued by the Board of Health. Signed Date G°3�GrL�OIyIC oD Inspections _ No.��1eti-�� �`7���I FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, , NM. V APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - U Complete System ❑ Individual Components Location ?r�yjA/�' Owner's Name ��Lrl; stir Map/Parcel# r/t' Address -; . 1✓1e/4 _L_ ot# _ Telephone# y f7rS- Installer's Name /��� f Designer's Name �� , 717 r Address14 Address Telephone# .. Teie hone�k p Z' TypJof Building-�rG�//7`f,/CI Lot Size sq. ft. Dwelling - No. of Bedrooms 7 _ Garbage grinder( ) Other =71vpe of Building No. of persons Showers ( ), Cafeteria . ( ) ther Fixtures ``/� Desigil,Flow (min. required) 77gpd Calculated design flow Design flow provided gpd Pan. Date/ _ Number of sheets Revision Date Title°/ Description of Soil (s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS eXI ,'1//7f p/ f4//Gi7 T` i'•f`, ! .yS 1llotli 'fin i 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 � Date :%C•.�„-•�/ Inspections. COMMONWEALTH OF MASSACHUSETTS FEE _ Board of Health, l ✓%GL,/j _ MA, 70 9 / CERTIFICATE OF COMPLIANCE Description of Work: UJhdividual Component(s) O Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired Q—Upgraded ( ), Abandoned ( ) by: U at Ir l4u rlJ _— has been installed in accordance with the p isions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No.,.'� r' i �, dated Approved Design Flow L U (gpd) Installer+ �jl/� Our � Designer i r Y Lt 4417 Inspector: 1IL LI r _ Date: ) The issuance of this permit shall 4ot be construed as a guarantee that the system will function as designed. No. !i Z`t ' FEE _ COMMONVIEALT1I OF MASSACHUSETTS Board of Health, /ft // MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is her rre-b)y Jgranted to; Construct( at 1L�11 ��� ��vlleyf ,ll Repair( ) Upgrade( tY Abandon( ) an indhidual sewage disposal system as described in the application for Disposal System Construction Permit No. h dated Provided: Construction shall be completed within -, i p �reeatsar��f the date of this 11�1 it. A11 local conditions must be met. Form 1255 RBV.51% A M Sulkin Co. ChMestprtSMq Date_ Board of Health W W W W W W W W NNNNN N N NNN�•-r �-+r.--•r �-.rr._.. N r V ch A W o . . . . . . .0 . . . . . . cy�p� yN= = c as coo c ��po ��C/�z� v�v�rnrov� Cv�� t"rvi C77d A¢ a lC pN. LQ. C ,Cr .. �' ,y. ryi A H pr JR.A a Sa•SSn S.y d y° �'Q' h a m -, ti A o �'� o' e� ° m m �° eo eo 5 �. ea �• �• m Z. 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