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HomeMy WebLinkAboutApp-Permit-ComplianceNo. / g 1146 ROUTE 26 SO. YARMOUTH, MA 02664 COMM®NWFALTIJ OF MASSACHUSETTS Board of Health,�P' YVI &O i& MA. FEE JD dD 7ku) APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade(n Abandon/) - ❑ Complete System /Individual Components Location IG 6 V Owner's Name R 1 Map/Parcel# "&x/ 136 Z.Z Address ( N 120 CL PJ , m a Lot# q Telephone# Installer's Name n Designer's Name R, r CA—di IA -C Address ",P Address f o , 13, 2S,6 �l Telephone# ZZ ( Telephone# S08 -1-7- „C1° 00 Type of Building Lot Size 6, 6(90sq. ft. Dwelling - No. of Bedrooms Garbage grinder 00 Other - Type of Building No. of persons Showers ( ), Cafeteria ( ) Other Fixtures �} /f Design Flow (min. required) `T 4 d gpd Calculated design flow 461 Design flow provided 44�n l gpd Plan: Date qI ) 27;,/ /G'i q Number of sheets i Revision Date Title -S1TF Rlt,,Try� Ric4A2 , f'V—A—'ti C . '�W �PYA, �-©T q ! A 6 0�j . Description of Soil(s) rune I um ,s" 2, 5V 614 Soil Evaluator Form No. Name of Soil Evaluator 12. 9, l A,4,i1AX . Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS ft7 ) D ne LO D- 6o), '} 1-0-AcA AAj(?.,u 4 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees tp not to place th system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed Date Inspections p7", No. FEE COMMONWEALTH O MA AC141J TT Board of Health, V' % fttM 4 A T>\. MA. ^ C s-s� Ty vdu hd CERTIFICATE Of COMPLIANCE :5; Description of Work: Individual Component(s) ❑ Complete:System=Theundersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired ( )Abandoned, by: is � A 111C �G�' ,r Chas been installed �i�nn accordance with the provisions , of 310 CMR 15.00 (Title, 5) and the approved design plans/as-built plans relating to application No. '77- - 43 s , dated Approved Design Flow (.gpd) Installer` (f �/ Designee �4-,il/ � /l Inspector: Date: The a7ce of this permit shall not 1>e construed as a guarantee that the system f ction as designed. /� No. FEE COMMONWEALTH LTH O MASSA'l,14i SETTS Board of Health, )l� , MA. y t DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair( at i �, G VN 2&C k .. -IZd . A-V V11 /Ic. Upgrade/ Abandon (,,,I'an individual sewagedisposal system Disposal System Construction Permit No. dated ?--13- 7' as - 3 - as described in the application for 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. Sulkin Co. Boston, MA Date � 7 Board of Health Al