HomeMy WebLinkAboutBHDC-24-122 permit/ plansrl
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Nola t 'T 122 CX %!/ - ay lib FEE 11 0
SC 0 A a COMMONWEALTH OF MASSACHUSETTS
d9- Board of Health, / MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
A
Application for a Permit to Construct( ) Repair( ) Upgrade(kf Abandon( ) - #Complete System ❑ Individual Components
Location —rliawq IT, Al, a
Owner's Name 1
Map/Parcel#
Address �'�� `r' few
Lot#
Telephone#
Designer's Name je
Address 2 "
Telephone# p�_ 2 7
Installer's Name P[U/7/� �� (�
Address 3� if
_
Telephone# , }, - - .
Type of Building fLot Size % ' sq. ft.
Dwelling - No. of Bedrooms _
... _. Garbage grinder( )
Other - Type of Building No. of persons Showers p O, Cafeteria ( )
Other Fixtures
Design Flow (min. required) ? t> gpd Calculated design flow Design flow provided 3119 V gpd
Plan: Date -74Z 12o7 z/ Number of sheets I _. - Revision Date
Title
Description ofSoil (s)
Soil Evaluator Form No. Name of Soil Evaluator ff'%_ /--,/W,'Zr % Date of Evaluation Ki6g4te
DESCRIPTION OF REPAIRS OR ALTERATIONS
. ,r
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to pot to plate the system in operation until a Certificate of Cgm�►liance has been issued by the Board of Health.
Signed — _ Date �ZOl
Inspections
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ok�cl �
16 d'I 10
2 COMMONWLALT14 OF MASSACHUSETTS ���
Board of Health, lw /1'li1o+, MA'
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) #Complete System
The undersigned hereby certify that the Sewage Disposal System; Consn'ucted ( ), Repaired ( ), Upgraded kf , Abandoned ( )
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. {i ��' dated f (� ,]�j _. Approved Design Flow --(gpd)
Installer 6k'4 x //} ! v,
Designer: -� F kC Inspector: - A L1 (� lei , Date:The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. - Y {" FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health, ise� 1 �t MA,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade G,) Abandon ( ) an individual sewage disposal system
at a%041% - /V. , _ as described in the application for
Disposal System Construction Permit No. Z� dated %
Provided: Construction shall be completed within three years of the date of this perirTt�[ All local conditions mast be met.
Form 1255 Rev. 5/% A.M Sulkin Co. Chafe wR MA Date Board of Health _---t- ��
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JUL 16 2024
HEALTH DEPT.
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