HomeMy WebLinkAboutBHDC-24-46 septic permit/planrho
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FEE 11
^l v COMMONWEALTH OF MASSACHUSETTS
C/ L + Board (f Health, �"C)UTtf
MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) UpgradeAbandon( ) - *Complete System D Individual Components
Location
Owner's Name Jrdr��„
Map/Parcel# 151
Address 141' C(
Lot#
Telephone#
Designer's Name 1
Installer's Name
Address ���(
S+ 7
Address 2SS4 1 t_'
G
Telephone# 5 .-(� 7.,9211
Telephone# �- Z73-0
Type of Building� _ _ Lot Size ZD-t sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 „„ 0 — gpd Calculated design flow Design flow provided 3MA gpd
Plan: Date 5�_"}-� Z(yZ Number of sheets _ �Revision Date
Title
Description of Soi(s) _l E7l — CZACCi - i1Z__ i r' j 5E�— PLAJL/
Soil Evaluator Form No. Name of Soil Evaluator M kPIM EE&IT�!4. Date of Evaluation
NO-0.
• • • '._ C_ _� • ! • 1
NN"W Y'076-W49 W _ r 1
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of T71 TLE 5 and
further agrees k not 16 place the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date ti '
Inspections
No, L 2-4. � )Vd�
COMMONWEALTH OF MASSACRUSET 6 FEE
Board of Health, MA. I ff
CERTIFICATE OF COMPLIANCE 4
Description of Work: ❑ Individual Component(s) Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired ( ), Upgraded ()6, Abandoned ( )
by:
at
has been installed in accordance with the provisio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to
application No. L 0 5 dated Approved Design Flow (gpd)
Installer ,
Designer:►JlS/r,?lC _�C,jnspector: _ { _ Date: / t_ �1 6
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. l - 1(P
FEE_
COMMONVTALT14 OF MASSACHUSETTS
Board of Health, _ AP.R., , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade QQ Abandon( ) an individual sewage disposal system
at 41l as described in the application for
Disposal System Construction Permit No.<f LJ .,dated
Provided: Construction shall be completed within three years of the date of dt' it. All local conditions must be met.
Form 1255 Rev SM A.M SuJkm Cc CMrlowm MA Date __ _ Board of Health`
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