HomeMy WebLinkAboutBHDC-24-29 Disposal system(-DT - Z� ~ 2-3 FEE L
COMMONV LALT14 OF MASSACHUSETTS 1WY
q6Board e f Health, Q►�' 7�pL l �
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - XComplete System ❑ Individual Components
Location 2.9
Owner's Name 149 CLAIWovks, LL
Map/Parcel#
3
Address a �•
Lot#
57
Telephone#
Installer's Name
Designer's Name M.) C.
Address
W �+ [TES E
Address u CC
Telephone#
—
Telephone# 50- D
Type of Building P6:51 A&, _
Dwelling - No. of Bedrooms
Other - Type of Building
Other Fixtures
Lot Size
+�r sq. £t.
_ Garbage grinder { )
No. of persons Showers ( ), Cafeteria ( )
Design Flow (min. required) ��`f qo gpd Calculated design flow T Design flow provided 4Z.z gpd
Plan: Date NNum�ber of sheets _ _ Revision Date
Title 29 AUuT paw* `s
Description of Soil(s) _- ,-
�-- • JW
Soil Evaluator Form No. Name of Soil Evaluator M. C p 4 NFAKjj & Date of Evaluation
1 • • • .♦ ' F
w _ cam. � • • �, • , _ ' ^' t � � � t � � C i
The undersign es to ' the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire t t to em in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date-- 3 RECEIVED
Inspections.—.---. _ EP 0 7 2Q24
-...__. -,HEALTH DEPT.
No. C Zq r LJ C'DT 2-4- 2-3 FEE
a��k� i
COMMONWLALT14 OF MASSACHUSETTS
e O�` Board r f Health, \ l� MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) - XComplete System D Individual Components
Location 2 -
io r5
Owner's Name
`L
Map/Parcel#
3
AddressI q 5 St.OTO
A '�7r
ITf '< C1�Mtl
Lot#
5,7
Telephone#
Installer's Name
„r
Designer's Name
Address �
lAj"I T�t;S � `7 4
Address 2k 511
(6
EWAROAM
Telephone#
22
Telephone#
0
Type of Building ��S l nQ fi l A L-
Dwelling - No. of Bedrooms 4-
Other - Tvpe of Building
Other Fixtures
No. of persons
Lot Size 5 ZOO - sq. ft.
_ Garbage grinder( }
Showers( ), Cafeteria ( )
Design Flow (min. required)_ gpd Calculated design flow Design flow provided gpd
Plan: Date - ) - i S - 202- Number of sheets . 1 Re%ision Date
Tide_ AULT Q.,-,)AAk'S 4-4&JF-7 YA& M4 70r2T
Description of Soil(sj _ M t i) A wJ D (Q- -;2H PLAJj
Soil Evaluator Form No. Name of Soil Evaluator M. P1j44=Aj1EL. Date of Evaluation _ jl__2 ij a
DESCRIPTION OF REPAIRS OR ALTERATIONS =iuj! c - Ajr'Z j I f(ra�N - q) <;`tT(c -[-y4nJ\t.
I�-(�Y ZTl(31
jLjo 6% ►u cA4 rt.,r.� C�4y4�c+��S La1r'r,- F; i=-� —.r o-P .46et 4 .StgAOu.� jv
i
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TTTLE 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 z_ C_
Inspections
No. b6 I 2C,
COMMONWEALTH OF MASSACHUSETTS
Board of Health, yA",.,,-7i4 I MA.
CERTIFICATE OF COMPLIANCE
Description of Work: U Individual Component(s) 0 Complete System
oK p) d
` )`' 11 to")FEE _
— i
mn fl ice rM out 4e
o_( /. "t)
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ()6, Abandoned ( }
V. ,,
by:
at
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 L- i41(gpd)
Installer k:Q,? -1 4 �� -
J
Designer,IC �A]C_�ix j�� ��c.„ _ Inspector: ,!E j '' _-- Dater/ f �i 7VJt�
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. � C 24 2
9
COMMONWEALTH OF MASSACI4USETTS
Beard of Healtlt,4A-1f.+t17L'>I' , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE 1 1 0
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (y) Abandon( ) an individual sewage disposal system
at L as described in the application for
Disposal System Construction Permit No.2 3 L/ , dated 2 • n L
Provided: Construction shall be completed within three years of the date of tbia-pcttifit. All local conditions must be met.
Form 1255 Rev 5/96 AW Sulkin Co Cto*k m MA Date,; 7 d t j..-_ Board of Health
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