HomeMy WebLinkAboutApp-Permit-ComplianceNo / FEE CsCd/
C®MM®"AMS® TH MASSACHUSETTS
�¢ LTH DEPT.`
Board of Health,1146 RaUTE 9A fi l'
APPLICATION FOP, DISPfflAT TV?YTdftUCTI®N PERMIT �P/IV;�
3
y Application for a Permit to Construct(1/Repair( Upgrade( Abandon( omplete System Ll Individual Components G
) Lkl
Location ��� �¢-X
Owner's Name Robert Dunphy
Map/Parcel# 5 / Z_
Address 31 Narrows Lane, S. Yarmouth
Lot# Q e-,15
Telephone# 7 6 0 -1318
Installer's Name . .G e. ,--
Designer's Name�'w p��y' �NL
Address, Denn 1 s , Ma . e
Address
Telephone#^
Telephone# Z
Type of Building �.�-' e Lot Size Z� sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (m�iin..,required)
r/ /16 gpd Calculated design flow 3 3 Design flow provided 3�- gpd
Plan: Date _19 IL l L Number of sheets % Revision Date
Title *R 1010-6-25-2 --<a-�Ti G f�'ll�1G'✓ G �2 2-/5 <- /�✓ G�-v/IJS/'l2y cT%d�J
Description of Soil(s)17e-
Soil Evaluator Form No. / �o �` rrU Name of Soil Evaluator / - PO 11!!;5 Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersi ed agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further a e to ox to lace syste peratio til a Certificate of Compliance has been issued by the Board of Health.
I - Signed Date
ra ,•
Inspections -CO
No. VV
;k-:- .tel ' dZ44 A
Y% FEE
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Board ofHealth, MA. GC ✓ ' �. )3
CERTIFICATE Of COMPLIANCE
Description of Work: ❑ Individual Component(s) Momplete System
The undersigned hereby certify that the Sewage Disposal SystAn; Constructed (-)1',kepaired ( ), Upgraded ( ), Abandoned
by: "ys� �"" �H -ArIC./V)C�0&a71A �E7r".d
at
has; been in tt led in accordance with the provisions of 310 CMR 15.0_0 ( ) and the approved design plans/as-built plans relating to
apn'N0. dated 5 �/' CTTi Ap ovecl De ow (gpd)
p �, o
Installer C
Designer: 544- 0--7' �S"•CV, Inspector: Date:
The issuance of this permit shall not be construed as a guarantee that a system will function as designed.
No. `✓� Z �J /� FEE ora' i
J COMMONWEALTH OF MASSACHUSETTS
Board of Health, �/�yL'ldz MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( -f' Repair ( ) Upgrade ( ) Abandon ( ) an individual sewage disposal system
at 57'� 7-z-: =- 1/!'% as described in the application for
Disposal System Construction Permit No. -C'�' dated >' O
Provided: Construction shall be completed within three years of the date of this permi l local conditions must be t.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date �� oard of Health