HomeMy WebLinkAboutApp-Permit-ComplianceNo. - 6 FEE
COMMONW"Wb(M4&�fTTS ej 4K) V
Board of Healtl 146 ROUTE 28 MA
0- YARMOUTH, MA OM
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair (1/l'eUpgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location0 t
Owner's Name
Address r
r
S,
Map/Parcel# IR�6
Lot#
Telephone# -6 L— 7 37 .
4 3
Installer's Name
Designer's Name
Address �0 P
Address
Telephone#
Telephone# 5�y
Type of Building Lot Size sq. ft.
Dwelling - No. of Bedrooms 4:Garbage grinder ( )
�.•-
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow "✓ Design flow provided 3 15E�( gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) Ap,9
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
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 Date
Inspections
/�K'
No. J '''?i0 � FEE
COMMONWEALTH Of MASSACHUSETT a t<:�,
Board of Health, MA. ��`
6'
CERTIFICAYE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (k<,Upgraded ( ), Abandoned ( )
by: �
at %L�'i': 3f r.,J sin `�yls� . a �-� ai O A
has been installed in accordance with the rovis ns o 10 CMR 15.00 (Title �'and thea proved design plans/as-built plans relating to
application No. 62 3 o dated _Q Approved Design Flow, (gpd)
Installer )-C &,/' / rbC
Designer: . ' ,/ / 41 .. Inspector: C. Date: _
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
C®MMONWFALT14 Of MASSACHUSETTS
Board of Health, MA.
DISPOSAL SYST CONSTRUCTION PERMIT
FEET U
Permission is hereby granted to; Construct( ) Repair (✓�- Upgrade ( Abandon ( ) an individual sewage disposal system
at L4ev c as described in the application for
Disposal System Construction Permit No. �, dated
6 wo S
Provided: Construction shall be completed within tl;Zgg,K of the date of this pe t. All local conditions ust be met.
Board of Health
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date ��