HomeMy WebLinkAboutBHDC-24-151 permit/plansNo.'6\x -Z- `. `4 t - 21 - k2-J FEE_
COMMONWEAfTH OF MASSAC14USETTS
Board of Health, y AQJV\ C)U1� MA.
VVVV APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - ❑ Complete System O Individual Components
Location -t -{
0m(5 rs cL-14' fzcoOwner's
Name (0 N
Map/Parcel#
ly a
Address
Lot#
Telephone#
Installer's Name
R061E$ U Q N C
Designer's Name
DQ�
Address 3b31) J� tl�� S f �t-�y� S . < 1
C , p V-:
Address ci3cl
J_
Telephone#
Telephone# C> 3 — L
Type of Building (x0e,IL)1`1 Lot Size aC) C)o sq. ft.
Dwelling - No. of Bedrooms _ Garbage grinder( )
Other -Type of Building No. of persons Showers( ), Cafeteria ( )
Other Fixtures
Design Flow (min, required) L t o gpd Calculated design flow (o (oo Design flow provided ��oO gpd
Plan: Date ��o �(�� �2 GNumber of sheets Revision Date --
Title
Description ofSoil (s) oJA1.8, L L' (`LOAan- AXP L r I S10`
Soil Evaluator Form No. _ Name of Soil Evaluator 84( __i-'?W LS: Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS - W ON c
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 p e e system ' o ration until a Certificate of m Hance has been issued by the Board of Health.
Signed Date SL
Inspections
HEALTH DEPT
q ^►aim
I —
FEE
COMMONWF LTII OF MASSAC14USETTS
Board of Health, 4AQ MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMMIT
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) - O Complete System O Individual Components
Location
Owner's Name ,
Map/ Pai-M#
! y j
Address
Lot#
_
Telephone# rl 2 1
Installer's Name
Ro6oE S V Q
C
Designer's Name f 1 C
t" Ad G,
Address
�L S
Address ` r
elephone#
y _
ne
Telepho# q 5,41
Type of Building Ottx;! I io ey ..___ Lot Size cz U O C) sq. ft.
Dwelling - No. of Bedrooms _ tC1 v Garbage grinder( )
Other -Type of Building No. of persons Showers ( ), Cafeteria ( )
Other FWMres
Design Flow (min. required) i l O gpd Calculated design flow Design flow provided G 420 gpd
/
Plan; Date _ % r (ti l 2 na.t'I Number of sheets Revision Date
Title
Description of Soils) 101t:� f A L4.j$ f "LQA eTj !�d „1CP, C f �1� k AA��i? ap �—
Soil Evaluator Form No. Name of Soil Evaluator(. LS Date of Evaluation S't Ley
DESCRIPTION OF REPAIRS OR ALTERATIONS , �>V :G L—sf f f <9h► (.N 10.n �_ _ r�
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TM E 5 and
further agrees to not to a system ' o don until a Certificate of mpliance has been issued by the Board of Health. 7
Signed_ Date !
G �
Inspections ..--. _
lamgwoe
COMMONWEALTHOF MSSCIIUSETTS q .bE �,
Board of Health, _ AA tl MA.
CERTIFICATE OF COMPLIANCE �-
Description of Work: Ue6ividual Components) O Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( }, Repaired (_�, Upgraded ( ), Abandoned ( )
by: ) _ } V .: C '—T 0
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, e� 1 ;'z dated yi 6•d L . Approved Design Flow 1 ? (gpd)
Installer
D8igner:1 to d ny Prt
The issuance of this perxdit shall sot be co
No.4' th E
�
nsKru
ed as a guarantee that the system will function as designed.
COMMONWEAU I OF MASSACHUSETTS
,board of Health, -/ A AA Z � - , Att
DISPOSAL SYSTEM CONSTRUCTION PERMIT
FEE SG
Permission is hereby granted to; Construct( ) Repair() Upgrade( ) Abandon ( ) an individual sewage disposal system
at 7 ���1 ;i�} Q, r O C.L� j as described in the application for
Disposal System Construction Permit No. ,dated `Y
r�7 V ff
Provided: Construction shall be completed within ear )f the date of thisparptit. All local conditions must be met.
Form 1255 Rev.5/96 AASuWn Co. ChelegamMA Date 1 i! Board of Health
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