HomeMy WebLinkAboutApp-Permit-Compliance1146 ROUTE 28 - —
No,
$0. YARMOUTH, MA 02664 FEE
MMONW1A]LTT4 Of MASSACHUSETTS
,rJaf- Board of Health, v 0 MA.
�P LICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) - Repair(V/Upgrade( ) Abandon( ) -�Complete System ❑ Individual Components
Location , ,E-5 L t E L V% ttiCAvzln�( W
Owner's Name (CL fj 2tll op SE(_,.Mn C
Map/Parcel# (S
Address -711
Lot# M 2-o
Telephone#
Installer's Name ,.Cf SEP I I L__
Designer's Name0 G --r, W
AddressC n� S
AddressW�Lt�S IPON,& ()V tV6 WIG
Telephone# '7-7E- — orb
Telephone# O — g
Type of Building C cS ( E ( L Lot Size sq. ft.
Dwelling - No. of Bedrooms Garbage grinder ( )
Other - Type of Building No. of persons Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) 3 3 ® gpd Calculated design flow
Plan: Date / 6 - y rcf% Number of sheets
Title 01 C 4i+(L.(-�- `t' SG`L.. 0r\Pr C h P C. PryI
Description of Soil(s) L OH M�A S
Soil Evaluator Form No.
DESCRIPTION OF REPAIRS OR ALTERATIONS
Design flow provided 5=0 ' gpd
Revision Date _*,!r/
Name of Soil Evaluator &AO (C ez_<� Y)Ckate of Evaluation
01--2,
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 topolace the g§SoA ;�ration til a Certificate of Compliance has been issued by the Board of Health.
S ned Date
t
'1
l Ipections
No
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COMMONWEALTH OF MASSAC14 SETTS FEE &D
Board of Health, MA. o 09-
CERTILICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s)Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (Upgraded Abandoned ( )
by: \ C (� E SC P `i- I c—
at ..� S L t C 14 Yui C liZ VYN o
has been installed in accordance with the provisions of 310 dIR 15.00 (Title 5) an the approved design plans/as-built plans relating to
application No. 4?7- dated2":` Approved Design Flow; I_j
Installer /4/ //:�>
Designer :d� /Ti'//t%% Inspector: Date: C d 1
The issuance of this permit shall not be construed as a guarantee that 4e system will function as designed.