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HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28_ -- _ _. .. ' N°' SO. YARMOUTH, MA 02664 FEE—1-56' COMMONWEALT14 OF MASSACHUSETTS Board of Health, !WAY44 l4 MA. APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair (i') Upgrade( ) Abandon( ) - ❑ Complete System ❑ Individual Components Location Owner's Name /�. jj ©�% Map/Parcel# Addressl� Lot# Telephone# Installer's Name Designer's Name ®;Li.14 �Q' Address �� Address a Telephone# -7 Z Telephone# 3,0 Type of Building AeB owewee- Lot Size sq. ft. Dwelling - No. of Bedrooms L Garbage grinder 4t1jyjj Other - Type of Building No. of persons Showers ( ) , Cafeteria ( ) Other Fixtures Design Flow (min. required) 3 6 gpd Calculated design flow 1l® Design flow provided 4� gpd Plan: Date / AX � Number of sheets /� Revision Qate Title e/fie V e Description of Soil(s) 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 n place the system in oneration until a Certificate of Compliana has been issued by the Board of Health. Signed Date 12 --hi Inspections :y No. `��/ `9D CO�'][MONWEALT14 Of MASSAC14USETTS FEE s � Board of Hecitth; t' Y�����/�f! MA. >G CERTIFICATE Of COMPLIANCE Description of Work: ❑ Individual Component(s) 'Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Yf Upgraded ( ), Abandoned ( ) by: at has been installed in accordance with the provisio qpf 310 CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to application No. 9�`t , }dated �-L 7 Approved Design Flow pd) .Installer ��/ d��/ ��j%� Designer: ���% G'� ' � � Inspector: Date: C- � 7 The iacnanre of this nermit shall not he rnnstrued ac a guarantee that the system will functidn as designed.