HomeMy WebLinkAboutApp-Permit-ComplianceI Af-11V9WW t . 1 ........ . �.-. . .
No. _ S� 1146 ROUTE 26;o , ZW
SO. YARMOUTH, MA 02$64
COMMONWEALTH OF MASSAC14USETTS
Board of Health,�i .1 , MA.
APPLICATION FOP,DISP®S L S SYSTEM CONSTRUCTION PERMI1
FEE
Gam"" ` '!10, 60
rvg-7-
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) -Complete System ❑ Individual Components
Location 2 ��r
Owner's Name
Map/Parcel#
e;VT f Address 251 co
Lot# p'L
Telephone# %J
Installer's Name
Designer's Name
Address
Address hf-�
Telephone# —
D Teleph?!1e#7372
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. re uired) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date r"�-
Title
Description of Soil(s) _
Soil Evaluator Form No.
OF
Name of Soil Evaluator
Date of Evaluation
cd
6
The undersigned to ' th a described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth r agr s to a tem . operation until a Certificate of Co plian e h been issued by the Board of Health.
Signed Date
Inspections
No. _ C/o�j FEE
Board of Health, MA. { L j`,'`J
Cal
CERTIFICAT Of COMPLIANCE D�
Description of Work: ❑ Individual Component(s) zsm;
mplete System
The undersigned hereby certify that the Sewage Dis osal Constructed( ), Repaired ( ), Upgraded ( ), Abandoned ( )
by:
at %A//1 111"7 /(
has been installed in a``cffrrd nce with the provisions of 310 CMR 15.00 Oide 5) and the approved design plans/as-built plans relating to
application No.. Z;7A1 , dated //" 7 -OV . Approved Design Flow (gpd)
Installer L)M
Designer: !�%//�I �t �L%j . Inspector:; /-/-rz7- Date:
The issuance of this permit shall not be construed as a guarantee "that the system will function as designed.
No. �fo / FEE
COMMONWEALT14 Of MASSACHUSETTS
Board of Health, QaCffl6-jjj
, MA.
W Y'
to DISPOSAL SYSTEA CONSTRUCTION PERMIT
Perm,i�ssion is hereby granted to; Construct( ) R pair ) Upgrade( ) Abandon( ) an individual sewage disposal system
at / ` ' IV described in the application for
Disposal Syste Con struction Permit No.0- 5� dated
S - `C
Provided: Con truction shall be completed within-titree years of tfte it. Al�Iocal conditi�smust et.
date of perm
Form 1255 Rev.5/96 A.M. Sulkin Co. Boston, MA Date ��—�_ Uy Board of Healt
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