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HomeMy WebLinkAboutApp-Permit-Compliance1 FEE D141 IZ) COMMONWEALTH OF MASSAC14USETTS leje'& 7 cP�C�/ Board of Health, YARMOUTH HEALTH D T. 1%"�X s �u�zL�✓I �� 1145 ROUTE 28 APPLICATION FOR DISPOVOYAM. W, WW'RUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgrade() Abandon( ) - ❑ Complete System C�4ndividual Components Location 417 Owner's Name Map/Parcel# 7 Address Lot# Telephone# Installer's Name �j D / Designer's Name Address q ` 6 f j,,iG Address Z m Telephone# Telephone# S-, (t., % %S " % VV Type of Building Dwelling - No. of Bedrooms Other - Type of Building No. of persons Lot Size sq. ft. Garbage grinder ( ) Showers( ), Cafeteria ( ) Other Fixtures Design Flow (min. required) .3J7e) gpd Calculated design flow S Design flow provided gpd Plan: Date Number of sheets Revision Date Title Description of Soil(s) _ Soil Evaluator Form No, Name of Soil Evaluator DESCRIPTION OF REPAIRS OR ALTERATIONS 4 �/ C li✓ sv / of Evaluation 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 place the system in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �/ t Date Y " Inspections s No. -69— ll/ "� -tf—#g FEE v COMMONWEALTH OF MASSAC14USETTS Board of Health, lavwMA. f CERTIFICATE Of COMPLIANCE �lt Description of Work: ndividual Component(s) C] Complete System The undersigned hereby certify that the S wage Dispos 1 System; Constructed ( ), Repaired a, Upgraded (> /Abandoned ( ) at has been installed in ccordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. d 6 / dated F . Approved Design Flow �i �--{gp Installer , - A �• Designer: &L. %C, r/', � �Ct L Inspector: _ ' (�C.l' � Date: The issuance of this permit shall not be construed as a guarantee k at the system will function as designed. No. !J f—.0 S Com' � FEE e�, COMMONWEALTH Of MASSACHUSETTS 6 Board of Health, ©G lillliL/�/ , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct( ) Repair(V) Upgrade (V Abandon( ) an individual sewage disposal system at 61 9 Z�,G, ! ��t.•�C/�/G W as described in the application for -�11Disposal System Construction Permit No.dated /— 3—U �. Provided: Construction shall be completed within c-vp-a s Cof the date of this ermit. All local conditions must be met. [N�l Form 1255 Rev. 5/96A*Sulkin Co. Boston, -/ MA (/� - Date � 4 , < Board of Health _) A v.//r