HomeMy WebLinkAboutBHDC-24-63 septic permit/plansi
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$I /-2/JT Z5`- U7 FEE _
COMMONWEALTH OF MASSACHUS£TTS
�t 06q Board � f Heallh, YN14I q14 0 AUq,
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade*) Abandon( } - Ll Complete System dfIndiividual Components
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Location �(JU 7 a b 4d- Owner's Name
Map:'Parcel# / Address /(/() JtfF1/
Lo!# Telephone#
Installer's Name Designer's Name 1
Address
3G3 ch,v s />1h S y Address
Telephone# •0�_ c Q Tele hone#
7L_ - i P mot - 7-7?_
Type o' Building (1C ,! tli t
Dwel'j:ig - No. of Bedrooms 3
Other - Type of Building
Othei Fixtures
Design Flow (min. requiFed) ?C gpd Calculated design flow
Plan: Date_ L Number of sheets
Title _ / ; / a
Description of Soil (s)
Lot Size sq. ft.
Garbage grinder( )
No. of persons Showers ( ), Cafeteria ( )
Design flow provided. yzz . ra gpd
Revision Date
G-� / o —
Soil Evahiator Form No. Name of Soil Evaluator /l%/ i„le / _ Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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The undersigned agree mstpdj the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees�o notto �lac�`the system in operation until a Certificate of CoRnp�ce has been issued by the Board of Health.
Signed _ _ Date
Inspeciuons
No. FEE_
COMMONWEA1 TII OF MASSACHUSETfS �-
Board of Health, MA. QC4 !
CERTIFICATE OF COMPLIANCE
Description of Work: Individual Component(s) O Complete System
The undersigned hereby certify that the Sewage Disposal System: Constructed ( j, Repaired (,(, Upgraded4 ), Abandoned ( )
at iL7 f" �,y /g!/
has been installed in accordance with the r 'sio of 310 CMR 15.00 (Title 5 ) and the approved design plans.," as -built plans relating to
application No. c r:dated ! C. Approved Design Flow 1,2�ai`(gpd)
Installer .
Designer: —T(_Inspector: l —
__ Date: t
The issuance of this permit shad not be construed as a guarantee that the system will function as designed.
No.
FEE
COMMONWLALTTI OF MASSAC-14-US£TTS
Board of Health, �Cfi Ut� MA
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair(/) Upgrade") Abandon( ) an individual sewage disposal system
at . ' „ !L j? t{ as described in the application for
Disposal System Construction Permit No. .b dated t .
Provided: Construction shall be completed within 44V*44r.A&q1'0`f the date of thisp;rmit. All local conditions must be met.
Form 1255 Rev.5/96 A.M. Sulkin Co Cha ONRMA Date` Board of Health
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