HomeMy WebLinkAboutBHDC-24-50 septic permit/plansa:
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COMMOWEALTH O� MASSACHUSETTS
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Board of Health,_{ �'� V C �'� M.A.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
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Location 1 S tJ fh M e (- S�_
Owner's Name T NN aY
Address Q�jY
Map, Parcel# —
Lot#
Telephone# 5O _ Z _ d 5 �3d
Designer's Name W }
Installer's Name QQLCS71 L0UQ, CO.L
Address 1
t 1
Address
iN Par;
Telephone# _ L E ? �- C� 1
Telephone# . o
Type of Building � i N)
Lot Size sq. ft.
Dwelling - No. of Bedrooms _
1,,
Garbage grinder( )
Other - Type of Building
No. of persons
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 33 o
gpd Calculated design flow
y f,y
Design flow provided .�: H gpd
Plan: DateNumber
of sheets
Revision Date
Title
Description of Soil (s) C, A r,-
t-rA� &n -
I'� l C ,
Soil Evaluator ForNo.
Name of Soil Evaluator etpp �Af r-� LQIcJ I S_
Date of Evaluation cL I!. r�pc3,ti
DESCRIPTION OF REPAIRS OR A LTERATIONS X of 1 1 1
CG �
t, �( 3 o U
I
GVlA✓e-s'S
,.
II
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 ' operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date l 5
hnspections
No. 4 '�Q 4�` FEE 1 1
COMMONWEALTH OF MASSACHUSETTS�/�.r
BoardofHealth, YM,^;� ?'1 ILIA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed { ), Repaired ( 1, Upgraded ( ), Abandoned ( }
by: fVL2L-t-� a. QUfL CCU N C _
at r_
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 Ng[ dated-? Approved Design Flow. _-.,,' y (gpd)
Installer Q -�,e ( fL C_ C , . -ff--/J C
Designer: lbG &foe F,.�tNc2.-Inspector: U _%�p _ Dater
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No.Z�-'► 5C`�
COMMONWEALTH Of MASSACHUSETTS
Board of Health, i Aa J1 qj-)J , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE .�)
Permission is hereby granted to; Construct( ) Repair( .� Upgrade ( ) Abandon ( ) an indi%idttal sewage disposal system
` at -rU as described in the application for
Disposal System Construction Permit No. DdV - D� dated �.
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev 5/96 A.M. Su kin Co. Chade*vrn, RA Date Board of Healtlf
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